Perspectives in Psychiatry training

  

What every postgraduate must know

FIRST EDITION

Edited by:
Dr. Suhas Chandran MD. Dr. Kishor M. MD.

     

ISBN: 978-93-5391-222-2

Copyright:

All rights reserved. The concept, the contents, print & publica on, in all its formats (hard copy & so copy version) are copyright proper es of

Dr Suhas Chandran

MRP:

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Minds United for Health Sciences & Humanity

Cover page:

Dr. Ajay Kumar

Editorial Office & Contact Address:

Dr Suhas Chandran
c/o Minds United for Health Sciences & Humanity, Sriganesh Krupa, M-18, Main Road, Vivekananda Nagar, Mysore 570023, Karnataka, India.

No part of this publica on may be reproduced, stored in retrieval or transmi ed in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the editors.

About the cover page

The Picture has two faces on either side of a sand hourglass mer which represents the reflec on of our teachers on students. A teacher’s training has an impact of discipline and me represented by the triangles and mer. The Timer also has a man in lotus posi on in medita ve state represen ng the need for focus and consistency in the training period.

Illustrations and Design:

SANTHILA DATABOT PVT LTD

Disclaimer

We have tried our best to ascertain the contents of this book. Kindly excuse if we have failed somewhere unknowingly. Mail us your sugges ons & feedback. All the ar cles and the informa on published in this book are only those of authors. Readers are requested to refer to ins tu onal or professional websites, books and journals to ascertain or access more informa on.
All rights are reserved.

+91 9449347072 &
+91 9686712210 mindsmysore@gmail.com

 

One day, in retrospect,
the years of struggle will strike you as the most beautiful.

– Sigmund Freud

Special thanks

To Professor

Shamasundar.C

whose ideas on human values mo vate us.

Acknowledgement

We are thankful to all the authors who have contributed to the book.

To Dr. Ajay Kumar for sharing our vision on postgraduate training and his enthusias c support in all our ventures

        

         

                       

List of contributors:

Foreword

Prof Mohan Issac

Preface

01 02 03 04 05

06 07 08 09 10

11 12

ABC of psychiatry

Dr. Kishor M

5

Contents

Transi oning to being a Post-Graduate from a UG 1 Dr. M.V Ashok

 

Choosing a thesis topic

8 Comple ng the thesis and is it possible to make it relevant 11

Dr. Vikas Menon
Dr. Pooja Patnaik Kuppili and Dr. Naresh Nebhinani

Grand rounds

Dr. Anil Kakunje

Preparing for examina ons

Dr. Ajay Kumar

The importance of medicine in psychiatry

Dr. Najla Eiman

15 18 23

    

Doing research and publishing in post-gradua on

27 Mental health care is a team effort 33

Dr. Suhas Chandran
Dr. Naveen Pai and Dr. Sundarnag Ganjekar

Facing the final exam : what the examiner expects

Dr. Alka A. Subramanyam and Dr. R.M. Kamath

Mentorship in psychiatry

Dr. Pra ma Murthy

Dealing with cri cism and difficult people

Dr. Shubhangi Dere

36 41 45

   

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20 21

22 23 24 25

26 27

The importance of one’s family

Dr. S.M. Manohari

The things that only pa ents can teach you

Dr. Nilesh Shah

Dealing with burnout in psychiatry residency

Dr. Sandip Deshpande

48 50 53

  

Lessons from the online world for a budding psychiatrist 58 Dr. Ravichandra Karkal

Student be my teacher! Teaching: a means to become a be er
psychiatrist 69 Dr. Rishikesh V. Behere

Importance of Peer Support and Networking

62 How postgraduates can use conferences for their benefits 65

Dr. Kiran Kumar K
Dr. Adarsh Tripathi and Dr. Raj Rana

  

Importance of Ethics

Dr. Bharathi G

Beyond Textbooks: Literature as an effec ve tool for students of psychiatry
Dr Ashlesha Bagadia

DNB training and DNB examina ons

Dr. Priya Sreedaran

Planning for super-specialisa on in psychiatry a er residency

Dr. Vijaykumar Harbishe ar

Preparing for a career in psychiatry a er post-gradua on

Prof. Sanju George

Becoming a psychiatrist

Dr. C. Shamasundar

72

77 80 84 87 90

     

Perspec ve of a resident 96 Dr. Deepali Bansal and Dr. Ajay Thomas Kurien

Award winning psychiatrists – A brief reflec on

Dr. Supriya Mathur

101

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A THEMATIC OVERVIEW OF CONTENTS

Theme

Title of the Article

Basics

1. Transi oningtobeingaPostgraduatefromaUG 2. ABCofPsychiatry

Coping/Resilience

3. Dealing with Cri cism and difficult people 4. Dealing with burnout

Learning

5. Grand Rounds

6. The things that only pa ents can teach you

7. Lessons from the online world for a budding
psychiatrist

8. Making use of professional conferences

9. Student as Teacher

10. DNB Training and examina ons

Integra ve

11. The importance of medicine in psychiatry

12. Mental health care is a team effort

13. Importance of Peer Support and Networking

14. Beyond Textbooks: Literature as an effec ve
tool for students of psychiatry

Ideals/Models

15. Mentorship in psychiatry 16. Importance of Ethics
17. Award Winning Psychiatrists

Planning ahead

18. Planning for specializa on 19. Planning for a career

Research

20. Doing Research and Publishing 21. Choosing a Thesis Topic
22. Comple ng the thesis

Challenges of the “Finishing line”

23. Preparing for the Examina on 24. Facing the Final examina on

Feed-back

25. Perspec ve of residents

Own Commitments

26. Importance of one’s family

Concluding

27. Becoming a Psychiatrist

Contributors

Dr. Adarsh Tripathi, Associate Professor, Department of Psychiatry, King Georges’ Medical University, Lucknow.

Dr. Ajay Kumar, Assistant Professor, Department of Psychiatry, Ins tute of Mental Health, Agra.

Dr. Ajay Thomas Kurien, Junior Resident, St. John’s Medical College Hospital, Bangalore

Dr. Alka A. Subramanyam, Associate Professor, Department of Psychiatry, TNMC & BYL Nair Ch. Hospital, Mumbai.

Dr. Anil Kakunje, Professor and Head, Department of Psychiatry, Yenepoya Medical College, Yenepoya (deemed to be) University, Mangalore.

Dr Ashlesha Bagadia, Perinatal Psychiatrist & Psychotherapist
The Green Oak Ini a ve, Annasawmy Mudaliar General Hospital, Bangalore.

Prof M.V Ashok, Professor, Department of Psychiatry, St. John’s Medical College Hospital, St. John’s Na onal Academy of Health Sciences, Bangalore.

Dr. Bharathi G, Assistant Professor, Department of Psychiatry,Hassan Ins tute of Medical Sciences, Hassan.

Dr. Deepali Bansal, Senior Resident, Cosmos Ins tute of Mental Health and Behavioral Sciences, Delhi

Dr. R.M. Kamath, Professor and Head, Department of Psychiatry, TNMC & BYL Nair Ch. Hospital, Mumbai.

Dr. Kiran Kumar K. Associate Professor, Department of Psychiatry, Vydehi Ins tute of Medical Sciences & Research Centre, Bangalore.

Dr. Kishor M., Associate Professor, Department of Psychiatry, J.S.S Medical College Hospital, J.S.S Academy of Higher Educa on and Research, Mysore.

Prof. S.M. Manohari, Professor and Head, Department of Psychiatry, St. John’s Medical College Hospital, St. John’s Na onal Academy of Health Sciences, Bangalore.

Professor Mohan Isaac, Clinical Professor of Psychiatry, Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia & Consultant Psychiatrist, Fremantle Hospital, Fremantle, WA, Australia & Visi ng Professor of Psychiatry, NIMHANS Bangalore, India

Dr. Najla Eiman, MBBS, MD, PDF in Neuropsychiatry, Consultant Psychiatrist, Chandigarh.

Dr. Naresh Nebhinani, Addi onal Professor, Department of Psychiatry, All India Ins tute of Medical Sciences, Jodhpur, Rajasthan.

Dr. Naveen Pai, Senior Resident, Department of Psychiatry, NIMHANS, Bangalore. Dr. Nilesh Shah, Professor and Head, Department of Psychiatry, L. T. M. Medical

College and General Hospital, (Sion Hospital), Sion, Mumbai.

Dr. Pooja Patnaik Kuppili, Senior Resident, Department of Psychiatry, All India Ins tute of Medical Sciences, Jodhpur, Rajasthan.

Dr. Pra ma Murthy, Professor and Head, Department of Psychiatry, NIMHANS, Bangalore.

Dr. Priya Sreedaran, Associate Professor, Department of Psychiatry, St. John’s Medical College Hospital, St. John’s Na onal Academy of Health Sciences, Bangalore.

Dr. Raj Rana, Senior Resident, Department of Geriatric Mental Health, King Georges’ Medical University, Lucknow.

Dr. Ravichandra Karkal, Associate Professor, Department of Psychiatry, Yenepoya University, Mangalore.

Dr. Rishikesh V. Behere, Wellcome DBT India Alliance Intermediate Fellow, Associate Consultant Psychiatrist, KEM Hospital Research Center, Pune.

Dr. Sandip Deshpande, Consultant Psychiatrist, Sexual & Rela onship therapist, People Tree Maarga, Bangalore.

Prof. Sanju George, Professor of psychiatry and psychology, Rajagiri School of behavioural sciences and research, Rajagiri College of Social Sciences, Kochi, Kerala.

Dr. C. Shamasundar, Former Professor of Psychiatry, NIMHANS, Bangalore.
Dr. Shubhangi Dere, Assistant Professor, Department of Psychiatry, MGM Medical

College, Navi Mumbai.

Dr. Suhas Chandran, Assistant Professor, Department of Psychiatry, St. John’s Medical College Hospital, St. John’s Na onal Academy of Health Sciences, Bangalore.

Dr. Sundarnag Ganjekar, Associate Professor, Department of Psychiatry, NIMHANS, Bangalore.

Dr. Supriya Mathur, Senior Resident, Department of Psychiatry, Jaipur Na onal University Ins tute for Medical Sciences and Research Centre, Jaipur

Dr. Vijaykumar Harbishe ar, Consultant Psychiatrist & Associate Director for Demen a Care, Nigh ngales Medical Trust, Bangalore.

Dr. Vikas Menon, Addi onal Professor, Department of Psychiatry, JIPMER, Puducherry.

Foreword

The experiences of postgraduate medical training have profound influence on one’s future life and work. Looking back at my own life, I know how much my mates, seniors, juniors and teachers as well as many of my pa ents and their families during my postgraduate days have contributed to shaping my professional career, my choices, my world view and my life, in general. A er years of graduate medical educa on, internship, much discussions and delibera ons about choice of a subject for specializa on and perhaps tough, compe ve assessments, one enters the coveted postgraduate training ins tu on with great expecta ons and aspira ons. But the world of postgraduate medical training, par cularly in psychiatry, is vastly different from those of the undergraduate days – smaller number of trainees, greater clinical responsibili es, accountability, longer hours of work along with studies, me-bound assignments, closer scru ny, supervision and monitoring of one’s work by seniors at various levels, etc.

Most entrants to postgraduate training in psychiatry are least prepared to face the reali es oftheirnewroleandtheenhancedexpecta onsfromthem. Therearenoknownrobust formal or informal mechanisms to acclima ze the new entrants to postgraduate training in psychiatry in most training se ngs in India. It has been well established that stress, depression and burnout are widely prevalent amongst trainees during their postgraduate training, all over the world. It is not so long ago, in February of 2015, that suicides by three psychiatry trainees (registrars) in three different psychiatry teaching hospitals in Melbourne, Australia (described then as a “perfect storm”) resulted in an Australia wide as well as global debate about high levels of psychological distress, par cularly in doctors aged 30 years and younger and what needs to be done to deal with mental health of doctors. Trainees need to be constantly supported to grow and acquire appropriate skills to deal with stress and adversi es during training as well as later in their career. It is in this context that the mul -authored book “Perspec ves in Psychiatry Training” edited by Suhas Chandran and Kishor is relevant.

Perspec ves in Psychiatry Training provides valuable and prac cal informa on that every postgraduate trainee always wanted to know (and should know) but did not know where to get from or could not find in any textbook of psychiatry or elsewhere. It provides instruc ons, guidelines and strategies to not only effec vely and successfully maneuver postgraduate training in psychiatry in India but also begin a professional career. It has brief, lucid chapters on clinical issues such as learning from pa ents, facing grand rounds, teamwork and course, curriculum and assessment related issues such as choosing a relevant topic for thesis, conduc ng research and publishing during the course, dealing

with and facing assessments and examina ons. Several chapters provide informa on about crucial issues such as dealing with cri cisms, dealing with burnout, “work – family” balance, benefi ng from mentors, peer support and networking. What does one do a er comple ng the postgraduate training? There are chapters on preparing for a post- MD (Psychiatry) career, planning for super-specializa on and transi oning to become a teacher. Other chapters include the benefits of wider reading of non-psychiatry books and benefi ng from the online world. What is most important about the book is that all the authors are passionate and experienced postgraduate teachers of varying seniority from different centers located in different parts of the country. I believe that Perspec ves in Psychiatry Training is a book that every postgraduate trainee in psychiatry in India and every young medical graduate wishing to specialize in psychiatry should possess.

Professor Mohan Isaac

Clinical Professor of Psychiatry
Division of Psychiatry,
Faculty of Health and Medical Sciences
The University of Western Australia & Consultant Psychiatrist, Fremantle Hospital, Fremantle,
WA, Australia & Visiting Professor of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore, India

Recommended Reading

Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians. A systema c review and meta-analysis. JAMA. 2015; 314: 2373-83

Kealy D, Halli P, Ogrodniczuk JS, et al. Burnout among Canadian psychiatry residents: A na onal survey. CANADIAN JOURNAL OF PSYCHIATRY. 2016; 61: 732-6

Swannell C. A perfect storm. Medical Journal of Australia, 2015; 202 (5) C1

Coverdale J, Balon R, Beresin EV, et al. What are some stressful adversi es in psychiatry residency training and how should they be managed professionally? Academic Psychiatry. 2019; 43:145-150

    

Preface

It gives us immense pleasure to put this book ’Perspec ves in Psychiatry training’ in the hands of the future psychiatrists. The mo va on for crea ng this book arose from the desire we and our teachers have had to contribute to the evolu on of the core principles in psychiatry training, and of course, the perceived need which we felt as post graduate studentsourselves. Theprac ceofpsychiatryrequiresvariousclinicalandinterpersonal skills not usually taught or used in the undergraduate medical course, and psychiatry postgraduates will have a lot of new and possibly confron ng experiences, and it is during these mes that they might look towards a guidance book can offer insight into the common challenges faced by a young resident, especially real-life experiences from people who have transcended similar situa ons.

With this in mind we wanted to create a book for the future mental health professional sharing the experiences of seniors on clinical work, academics, research and other relevant issues. We were lucky to have some exemplary teachers, who guided us with our challenges and endeavours, and they have been greatly inspira onal in making this book into reality. The chapters enclosed provide students with informa on, strategies and resources for a career in psychiatry as they adjust to the milieu of post-gradua on, and is a percola on of the most useful approaches which can be used in dealing with the hurdles faced during the course It is a unique experience to stand on the shoulders of these mentors and to have a glimpse into most things that lie ahead in the psychiatry residency. Exposure to such material in these forma ve years can help the student develop complex thinking skills, expand their thought process, and help prepare them for their future life as a professional.

Having an idea and turning it into a book is as hard as it sounds. The experience is both internally challenging and rewarding. This is ul mately a book that we wish we had available when we started our post-gradua on and our best efforts have been to ensure that there is something useful in this book for every postgraduate who reads it.

Though we have a empted the tle of this book to be crisp, we like to emphasize that the processes of training and learning are inseparably bi-direc onal and there is no limit to learning. Even the trainers are learners and a part of the learning includes the art of training. Our deepest gra tude to all the individuals who helped make this book a reality including our well-wishers, authors and readers who have supported us from the beginning of this ini a ve. We look forward to your feedback and support, as always.

Dr. Suhas Chandran and Dr. Kishor M.

Prof M.V Ashok,

Professor, Department of Psychiatry,
St. John’s Medical College Hospital,
St. John’s National Academy of Health Sciences, Bangalore.

Email id : mysoreashok@gmail.com

TRANSITIONING TO BEING A POSTGRADUATE FROM A UG

Welcome to a career in Psychiatry! Great moment indeed, to feel you are accepted into a PG training program. Medical fraternity has a way of showcasing of gran ng of privileges and this new step takes you ahead by a quantal leap. To feel that a group of professionals, who have become recognised for their knowledge and acumen, have actually permi ed you to enter their bas on is a goose-bump inducing moment indeed! Congratula ons! Start by believing that you have been justly granted the visa into a new journey. You are not here only by chance!

Psychiatry is however not much taught in the UG program even today. It is likely that you have not had much training here. This may leave you with trepida on about what to expect, nay, even make you wonder, if you have made the right choice at all! And not all friends and families would be greatly apprecia ng the choice, even in the contemporary world. It is possible that some of you have worked in other special es and then come in to psychiatry. Some of you have probably not worked at all for a few months to few years in the medical field, due to personal reasons, and therefore, feel raw as a doctor to begin with. The issues men oned below apply to all of you. Of course, a rare few of you may have worked in the mental health field a er UG training, before your formal entry into PG training. You are probably already fired-up to display your knowledge and push ahead. That is some advantage indeed and will last for quite some me. Build on it if you wish to stay ahead!

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Your view of the world will also undergo some reflec on. Some of you may become more aware of this than others. Those holding liberal views may experience dissonance when they see structured ways to understand case history involving human lives. This method may appear limi ng. However, it is good to remember that a lot of thought has gone into ge ng such methods into the system. So, hold yourself back and learn. You will enjoy understanding quan ta ve and qualita ve approaches, in due course of me. Those with a conserva ve view may find it hard that even the ‘most obvious’ of possibili es need corrobora on and that valida ng the informa on from ‘the unwell’ person is necessary. Welcome to the world of collabora ve decision making. This will take some learning and ge ng used to. And remember, you are here to learn and prac ce received professional wisdom and not what you generally understood about people and how to react to them.

A key difference from UG training can be the need for self-driven study methods. The levels of structured training may vary across PG training centres. Teachers do vary in their ability to encourage study methods. Some may be rhetorical, some pon ficatory while some may be frankly living in the past, but many will guide you if you ask. It becomes necessary for you to pose your own ques ons, based on your observa ons and ongoing discussions with friends and colleagues. One needs to keep all avenues for learning open and chase them vigorously.

Learning is ini ated by your own ques ons and a steadfast refusal to mix-up hunches for facts. Students, especially from most sub-con nental schools, may not have been taught ‘how to learn’. This limita on can perhaps also be side-stepped during UG days, where a few specified text books may be adequate. But, as a PG, you need to develop a style of inquiry-based learning. A few rare mentors may guide you through this process. Most teachers may not be able to. Trying to develop a method that suits your style but helps you learn the subject, the professional methods and the prac ces and help you communicate effec vely, is a must. Trying to limit your learning to the extent of just answering the way your teacher expects (may have been possibly sufficient during UG days) would be a sad loss of opportunity to develop yourself and grow. Group studies are s ll possible, but get rarer. This may also get impacted by compe on too. These may be new experiences.

Unlike a UG, a PG must focus on in-depth understanding of the subject. This ought to become your avowed goal. As suggested earlier, you cannot be sa sfied with just knowing what to answer on rounds, although knowing that, does help maintain your peace and sleep! You must actually get used to inquiring about every decision made, in order to learn. The more you ask, the more you will learn. Even if an unhelpful senior doctor brushes aside the ques on (and there are well-known ways of doing this!), you must persist. Developing this gump on is your first building block. As long as you are not being antagonis c in your ques oning style, it is a very valid way to learn.

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And that learning should be furthered the same day, by checking out from books and discussing with others. I have seen PGs who have actually moved on to even develop protocols for easy decision making in the department, a er star ng out this way. All seniors will eventually appreciate such an a tude.

Unlike a UG who would be expected to know basic informa on, you should be making logical arguments. This impacts how you learn to formulate case histories and discuss clinical data. It should also be applied to seminars and disserta on protocols. Logical thinking is a must in all the discussions with other department colleagues, as part of joint case-sharing. It involves reflec ng on what is being expected of a seminar topic and keeping a coherent thought process, throughout the presenta on. It involves ensuring that informa on, under all headings and subheadings of history and clinical examina on remain logically connected and consciously coherent to you.

You are here for training, but this is about training to work, not just answer text-book ques ons. Skills, rather than knowledge, will be the focus. As a UG, studies (MBBS) and work (Internship) have been largely separated. Here it goes hand in hand, but work gets primacy. And the ini al feedbacks will be on your day-to-day work. Conver ng concepts to working procedures is what you ought to master. PG training centres vary in terms of how much shadowing and appren ceship is allowed-for, before asking you to work and deliver. Given the need for a confident and organised approach to work (which your team would be desperately wan ng out of you), it is not surprising that milder personal challenges such as shyness, fear of authority, concentra on abili es, language limita ons and subop mal me management methods etc become unmasked during the early days of psychiatry (or any PG) training. And being a new student of psychiatry, even though you have done well to reach here, these might appear to be a huge problem. You may blame your parents and teachers. For e.g., you may feel your parents never trained you for independence. Or that your earlier teachers never helped you think, etc. If you are seized by such thoughts, it is not at all unnatural! It is important to discuss with designated mentors and/or senior members of the team openly, to get your working (and even learning methods) challenges resolved. Do not think that you must be approved on all counts and by all team members or that having a limita on is something to be embarrassed about.

Working with other team members is another key area of PG training. Each specialty has its own set of associates and co-workers, who help achieving the final clinical outcomes. Learning to work effec vely and cheerfully with them is a must. Psychologists and Psychiatric Social workers may ini ally seem to be very different in their approach to clinical tasks. Being respec ul and openly curious will help reduce this mystery over me. Nurses are infinitely helpful, if you will only ask them. And ward aides can teach you a thing or two every month, if you can have some cheerful banter

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with them. Unlike how you were as a UG, you need to get involved with all aspects of the work eco-system. Gradually, you will learn to become an effec ve manager of teams.

It is not just a transi on from UG to PG that is happening at this point in me, but also a transi on from youth to young adult status. A number of personal events would be running in parallel, in your life. It may be hard to separate them from impac ng your day-to-day work. Effec ve management of your own emo onal resources and the suppor ng social networks, while con nuing to focus on learning, is a wonderful introduc on to life itself. Embrace it and learn, rather than becoming helpless and demoralised. Elsewhere in the book, there are pearls of wisdom on me management. I would add to this: a course on developing, maintaining and managing composure! The more you are aware of your internal workings, the more you are willing to have friends and communicate with them, the more likely you will come out happy and successful. Most do.

Wishing you a warm welcome into the profession! Cheers for a great career

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ABC OF PSYCHIATRY

Dr. Kishor M,

Associate Professor, Department of Psychiatry, J.S.S Medical College Hospital, J.S.S Academy of Higher Education and Research, Mysore.

Email id : kishorm@jssuni.edu.in

Strange as it seems, there are ABCs of everything but not so much in psychiatry. The adjec ve “ABC of”means the basics or the most important aspects or ‘the founda on of’, hence we can never overlook the ABC of Psychiatry. But what could poten ally cons tute an ABC of Psychiatry?

A

Acknowledging the person in distress should be the first and foremost aspect of psychiatry training. An illness is that part of an issue which a person manifests or presents with. Unfortunately, training in psychiatry is moving away from the “person”to“justhis/herillness”,which isagainstprinciplesofhealthsciences& humanity. A person is a part of the society that is in dynamic interplay with innumerable factors with his or her inherent unique strengths & vulnerability. Hence a postgraduate in psychiatry should constantly try to understand social, cultural, economic & biological issues that affect the individual. Acknowledgement is much more than listening to a person, it means understanding the individual as a whole. Psychiatry training should begin with humility and a valida on of the person whom we intend to serve. It may be difficult to accept, but the fact is that a person with an illness can live or survive without a doctor, but there can be no doctor who can learn or earn without a person with illnesses.

B

Building upon the basics. The founda on of medical sciences is built upon interplay of physics, chemistry and biology. It is important to note that psychiatry has addi onal founda ons of psychology, sociology & anthropology as well. It is impera ve that the medical sciences learnt from MBBS course are never given up

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once postgradua on begins; it would be foolish to have a skewed view of everything from the perspec ve of only psychiatry! A psychiatry postgraduate should never undermine his/her medical science knowledge. The other facet is in understanding psychopathology and psychopathological phenomenon in every person with an illness. A postgraduate who jumps to conclusions without elici ng them is half-baked, and need further improvement in management and communica on skills to alleviate a pa ent’s distress. Some postgraduates may start diagnosing pa ents with their own assumed methods, while disregarding me tested criteria such as the Interna onal Classifica on of Diseases. This is a ma er of concern. Oversight and disregard for recognised systems and reputed bodies that have laid founda on to psychiatry is indeed a serious flaw that is seen with emerging psychiatry postgraduates.

It is important that a psychiatry postgraduate learns about psychotherapy and psychosocial management alongside pharmacotherapy, and apply these principles in formula ng a management plan for every pa ent. Psychosocial and psychotherapeu c interven ons form the founda ons of psychiatry, and a flaw in the founda on would impair a psychiatrist all through professional life, as, something which is not u lised in training is usually not prac ced during independent clinical work either. There is a large body of evidence about the benefits of psychological therapies and rather than being side-lined because of the advancements in pharmacotherapy, psychotherapy will con nue to remain an indispensable part of mental health services.

C

Communica on with compassion is essen al for every psychiatry postgraduate. A training where there is no emphasis given for “communica on with compassion” is detrimental for the resident’s professional career & counter-produc ve for psychiatry services. Communica on is listening and responding by appropriate verbal & non-verbal means. Compassionate communica on is “being genuinely concerned” in the process of interac on. Postgraduates have to con nuously make an effort to learn the art of listening and understanding the inner experiences of the pa ent. It can be learned and it needs persistence. It is interes ng that the art of listening can be really tested in different scenarios such as; interviewing children, elderly, couples in distress, agitated individual, family in anguish etc. Listening to people from so many linguis c & sociocultural backgrounds is unique to India, and such differences are seen every hundred kilometres in this land. As teaching hospitals cater to them more o en, postgraduates should be sensi ve to this diversity and keep in mind the bidirec onal rela onship between the pa ents’ cultural background and their illness.

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Appropriate interjec on, paraphrasing, clarifica on, reciprocal acknowledgement in the interac on with the person, both verbally and non- verbally is at the heart of communica on, which a postgraduate in psychiatry has to con nuously learn. In this process, if one has no heart or does it “mechanically”, it is a disservice to this profession. It is important to be clear that “transference & counter-transference” issue is unrelated to being compassionate. It also needs to be clarified here of some scep cal ques ons such as “what if we are burdened” by the process of being compassionate to a person & family in distress. Being compassionate in communica on never burdens anyone, in fact it makes every interac on gra fying and reduces medico legal issues. It ensures that the professional journey in psychiatry is far more rewarding. It’s amazing that even today when people are becoming more and more self-centred, there are millions of people who seek our service and come with so many people involved in their care and it helps, so does compassionate clinician’s communica on skill in the emerging “dehumanising” digital world – that is ge ng doctors neck deep in legal issues.

ABC of psychiatry is for those postgraduates who wish to excel in services and reside in the hearts of people.

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CHOOSING A THESIS TOPIC

Dr. Vikas Menon

Additional Professor, Department of Psychiatry JIPMER, Puducherry.

Email id : drvmenon@gmail.com

“Research Is to See What Everybody Else Has Seen and Think What Nobody Has Thought”

-Dr. Albert Szent-Gyorgyi, Nobel Prize winner

One of the most exci ng, yet, in mida ng exercises in the postgraduate residency programs is the thesis or disserta on work. In most ins tu ons, the residents are expected to finish selec ng a topic and submit the en re research protocol for approval within the first 6 months of residency. Small wonder that with none to minimal prior experience in research, most residents, struggle to select a topic that is achievable and at the same me impress experts in the field.

Rarely, the guides themselves may thrust a research idea on the resident who is all at sea and therefore, willingly accept anything given to him/her. However, many a me, the guides may ask residents to scout for poten al narrow topics within a broader area which fits into the focus area of the guides. Whatever the situa on, the residents would do well to remember the following few caveats while selec ng a topic for the thesis:

1. Follow your interests – If you have already had some prior experience in research through studentships or are interested in a par cular area, explore the possibili es of working in that area with your guide.

2. Begin by reviewing the literature and brainstorming on the broad topic assigned to you – If you have been assigned a topic, go back and read about it. Make use of the vast resources available on the internet. Do some free lis ng of ideas by wri ng them down or saving it on the desktop. Write an outline of what you wish to study. Although what you write may not be perfect, wri ng helps to crystallize your thoughts and you will be able to show it to your guide/supervisor for feedback. Saving the literature review that you have done is a must for future reference. To know the best way to search the literature requires some orienta on. Fortunately, online resources such as PubMed provide free tutorials that are helpful in this regard.

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3. Generate novelty by synthesizing ideas or concepts from previous papers – Do not spend me looking for that big bang research idea. It is prac cally nearly impossible to find out something that has NEVER been worked upon before. A be er approach would be to combine ideas from different papers so that you can look at an old idea in a new way. This would be much more appealing to clinicians and experts. To cite an example, presence of inflamma on in depression is a well replicated finding. Vitamin D is known to have an -inflammatory proper es and is also found to be deficient in depressed individuals. So, would vitamin D supplementa on improve inflamma on and consequently, depressive symptoms? This is an example of building a research hypothesis.

4. Make methodological improvements to exis ng work – It is a common tendency for residents to try and replicate a previous study with absolutely no changes to the methodology. This only leads to a dry recita on of previous results and is unlikely to impress professionals or find favour with reviewers. Ge ng hold of a prior similar work in the area is a good star ng point but residents MUST strive to make improvements to the exis ng work. To do this, always read the limita ons sec on of the reference paper. Even if you can correct one or two of the limita ons men oned therein, your work will be be er than the earlier one and will stand a good chance of ge ng recognized and published.

5. Consider the resources available in your centre – Some mes you may have hit upon a good topic but the resources at your centre in terms of pa ents, me and money do not make the idea feasible. An example would be when the sample size calcula on for your study indicates that you need a sample of at least 100 pa ents with that disease condi on but your hospital a endance sta s cs indicates that only 50-60 such pa ents can be recruited in the 12-18 months available for data collec on. In other words, select topics that can be done within the available me-frame. To address these concerns, always pilot test your idea for a month or so to check the feasibility before finalizing your research protocol.

6. Refine the topic as you go further – It is o en difficult to an cipate all the possible issues with a topic beforehand and you may need to refine research ideas on the go. Some mes, this may involve studying an addi onal parameter because you chanced upon an ar cle that you did not have access to before you submi ed your research protocol. It is good to be flexible in such cases and add the parameter if you and your supervisor concur that it may add value to the study. It is now-a-days easy to keep abreast with scien fic literature because PubMed allows you to create an account, save the ini al literature, search and modify se ngs for automated e-mail updates. One thing to be kept in mind here is that you may need to go back to the ethics commi ee to ensure that they approve any amendments that you may make to your already approved protocol.

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In summary, a thesis topic must be feasible, relevant and achievable. The results should reflect an advancement over previous works and at the same me, provide ideas for further research along the same line. Discussion with guides and peers can go a long way in allaying your anxie es and developing your thinking skills. Choose a thesis topic that fulfils the above provisos as well as piques your interests and you will do well. Happy researching!

Recommended Reading

1. Raveendran R, Gitanjali B, Manikandan S. A Prac cal approach to PG disserta on, New Delhi, Jaypee Publica ons, 2012.

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COMPLETING THE THESIS AND MAKING IT RELEVANT

Pooja Patnaik Kuppili, Naresh Nebhinani
Senior Resident, Additional Professor, Department of Psychiatry
All India Institute of Medical Sciences, Jodhpur, Rajasthan
Email id : drnaresh_pgi@yahoo.com

Importance of thesis to postgraduate students:

A thesis is an essen al component of postgradua on. Submission of the thesis is a mandatory requirement for awarding a postgraduate degree in Psychiatry in India. Apart from this, it allows the student to foray into the world of research providing a learning opportunity for formula ng a research ques on, genera ng a hypothesis, developing study methodology, collec on, analysis, and interpreta on of data and further, paving the way for scien fic wri ng and dissemina ng the research findings. The most important learning point from a thesis is developing a systema c thought process, with a keen eye for cri cal appraisal, which will aid the student to develop into an excellent clinician. With this background, this write up aims to provide insight to the budding psychiatry trainees about various aspects of comple ng the thesis and how to make it relevant.

Barriers for completion of the thesis:

Before we embark on a journey about the ni y-gri y of comple on of the thesis, it might be prudent to have a bird’s eye view of the possible barriers for comple on of the thesis. “Planning fallacy,” which means mis-an cipa on about comple on of the thesis needs to be considered. Various reasons leading to planning fallacy as well as cogni ve biases for comple ng a thesis with examples are enumerated in the table below:

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Skills of the student

A ributes/skills of guide Departmental issues

Faulty considera ons while selec ng the topic!

Unexpected future plans and problems

Not learning from past experiences

Blindly relying on others experiences

Personality a ributes

Miscalculated deadline/Poor me management

Deficient wri ng skills, the ability for cri cal appraisal, poor knowledge about research methodology can hamper the progress of comple on of the thesis.

Not providing adequate, mely input, not able to supervise the research work properly.

The difference of opinion between the faculty members – Departmental poli cs.

Topics which are not feasible due to financial or infrastructure reasons.

The student thinks: I will collect data from the outpa ent clinic every Wednesday. However, later on, the student is posted to work at an outreach centre in the community every Wednesday.

I have never completed anything on me earlier- so, I will not be able to do it – I give up.
Be ready to learn from nega ve experiences, avoid nega ve connota ons, consult the guide.

My seniors have completed their thesis a month before the deadline. The student might be overconfident/under confident and resultantly miscalculate.

Be ready to learn as you proceed. Be ready for some hard work

Persons with anankas c personality might need a longer dura on of me to complete the thesis. Persons who are procras nators start work late. Be ready to personally grow by shedding unproduc ve habits

I need to submit the thesis by Monday 9:00 am. I will complete by Sunday night. Suddenly on Sunday evening, there is a problem with the student’s laptop.

         

Reason

Examples

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Steps for timely completion of the thesis:

1. Choose a feasible topic: All that begins well ends well! Selec on of a feasible thesis topic is the first step towards the comple on of this mammoth task. The topic must be selected a er considering the financial and infrastructural limita ons. Also, if it is an interdepartmental thesis, logis c issues need to be worked out. For example, imagine the plight of a student whose thesis is based on blood-based biomarkers – finds the lab to be locked or the refrigerator (to store samples) not working a er collec ng sample with difficulty! The FINER mnemonic (i.e. research ques on must be feasible, interes ng, novel, ethical, and relevant) can aid the student in formula ng research ques on.

2. Be clear with aims, objec ves, methodology and sta s cal analysis:

Understanding the background, aims, objec ves of the study, and research methodology are essen al for mely progress of the thesis. Without which, it is like searching for a needle in the haystack! It is advisable that the student a ends a workshop on learning research methodology and sta s cal analysis before star ng the thesis work so that he or she is primed for the be er conduct of the thesis.

3. Make a meline and set targets: Rome was not built in a day! Similarly, it is essen al that the student works on the thesis consistently. Being a postgraduate trainee, one is expected to carry out clinical, academic responsibili es in addi on to the thesis. Hence, it is essen al that the student balances clinical and academic work with thesis work by planning me slots and preparing a me table in advance. It is also advisable to break the larger task into smaller targets for the easier accomplishment of the task. However, this also needs constant evalua on and introspec on about the progress of work and making changes when necessary.

4. Discuss with guide mely: For mely comple on of the thesis, constant supervision by the guide is necessary. Upda ng the guide regularly with thesis work and mely feedback which can be incorporated to improve the quality of work. It is essen al to inform the guide about any barriers in carrying out a thesis which can be discussed and rec fied in me.

5. Start wri ng on me: This is the last lap of the thesis race, which is extremely important! A student might become complacent by the me, data collec on, and analysis has been done. Hence, it is necessary for the student to remain mo vated to write the thesis regularly. For example, the student can make a me table making weekly targets by devo ng appropriate me for various components of a thesis such as introduc on, review of literature, methodology, results, and discussion. The student must also keep in mind to adopt the ethical prac ce of wri ng a thesis by avoiding plagiarism.

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6. Most importantly, stay healthy and relax!: It is necessary for the student to be focussed yet relaxed throughout the postgraduate training period in the background of the hec c schedule. Hence, he or she needs to be healthy, physically as well as psychologically. Adequate physical and relaxa on exercise, including yoga, medita on, balanced nutri onal diet, sound sleep, strict no to any drug of abuse, can help the student in this regard.

7. How to make thesis relevant: A thesis might be viewed as an irrelevant exercise by some students. Besides, the mandatory requirement, the wri ng of thesis is a wonderful opportunity to develop various skills which are necessary for clinical prac ce.

These are the following ways in which the thesis is relevant to a

postgraduate trainee:

a. Clinically relevant: The selec on of a clinically relevant thesis topic is an essen al step in bridging the gap between research and clinical prac ce. For example, assessing the endophenotypes of any psychiatric illness will aid in early detec on of high-risk groups. Thereby, preven ve and early interven on efforts can be undertaken. Another example is research carried out on predictors of response to psychotropic medica on, can be u lized in determining the choice of medica on in clinical prac ce. Hence, carefully choosing a relevant thesis topic can reduce the distance of “bench to bedside prac ce” as well as encourage the prac ce of evidence based medicine.

b. Exposure to research methodology and sta s cs exposure: The thesis usually provides an opportunity to have the first-hand experience in carrying out research as the research exposure is currently limited in the undergraduate curriculum. Sound knowledge of methodology and sta s cs is essen al for cri cally reviewing literature as well as for planning future studies.

c. Publica on: Thesis comple on is actually “incomplete” if it is not published! It is crucial to disseminate the research findings to guide the clinicians as well as researchers. Publica ons in indexed journals are a prerequisite for senior resident or faculty posi ons at academic ins tu ons. Few ques ons about the thesis and its publica on are invariably asked in the job interviews. Hence, it is necessary not only to complete but also to publish a thesis on me.

1. Agu N. Variables a ributed to delay in thesis comple on by postgraduate students. Journal of Emerging Trends in Educa onal Research and Policy Studies. 2014; 1;5(4):435-43.

2. Ho JC, Wong PT, Wong LC. What helps and what hinders thesis comple on: A cri cal incident study. Interna onal Journal of Existen al Psychology and Psychotherapy. 2010;3(2).

3. Buehler R, Griffin D, Ross M. Exploring the” planning fallacy”: Why people underes mate their task comple on mes. Journal of personality and social psychology. 1994;67(3):366.

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RECOMMENDED READING

GRA

Dr. Anil Kakunje Professor & Head, Department of Psychiatry Yenepoya Medical College Yenepoya (deemed to be) University, Mangalore Email: anilpsychiatry@yahoo.co.in

Grand rounds are methodology of medical educa on and inpa ent care, consis ng of presen ng the medical problems and treatment of a par cular pa ent to an audience consis ng of doctors, residents, and medical students. It was first conceived by clinicians as a way for junior colleagues to learn clinical skills prac cally. This tradi onal facet of pa ent care is o en not given enough importance. In the late 19th century, the Johns Hopkins Medical School, led by Sir William Osler, introduced bedside teaching as a new approach to clinical educa on.

A typical grand round means a ‘chief consultant’ moves from bed to bed in a hospital se ng with junior colleagues, residents and trainees discussing cases, important findings, finalizing management plans and asking ques ons. The ‘chief’ is usually the most senior, experienced and esteemed member of the group. He takes the role of a chief facilitator. The signs and symptoms are keenly observed and discussed. The chief clinician shares his experiences related to individual cases with the juniors and students which is of immense value and unavailable in books to read.

Grand rounds in psychiatry usually takes a slightly different course, in that the en re trea ng team, consis ng of the consultants of Psychiatry, Psychology and Psychiatric Social Work, along with their respec ve junior faculty, senior and junior residents as well as trainees sit together and discuss a given case at length, which is usually presented by the junior resident in charge. It generally happens on a weekly basis on a prefixed day of the week and con nues as a tradi on. Pa ents are called to the interview room and a detailed mental status examina on is done in the presence of senior consultants, and details are clarified from the pa ent as well as caregivers. They are also involved in the discussion and form part of the decision-making process.

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ND ROUNDS

Once this is done, residents and trainees are asked ques ons and given feedback regarding their mistakes and sugges ons as to what they can do to improve themselves. Grand rounds some mes incorporate formal topic discussions too, where students are given certain assignments in the previous week, and are tested upon these topics a er an oral presenta on of the same. It would be helpful to have a separate notebook for the ques ons asked in rounds and to note down the feedback received. This could not only prove useful prior to exams but it would be good measure to supplement the textbook reading of the concepts with these ques ons.

Treatment & Teaching happens simultaneously. Dugdale coined the term ‘Consultoscopy’ for this ac vity. The star ng point of the discussion would be the pa ent’s issues but can digress to far flung areas or even inter-disciplinary things. There will be on-lookers and lot of audience who will be interested to listen to the discussions. The resident has to present the case in front of a big audience who will go into minute details, ask for more details, clarify things, go into probabili es, ask ques ons and discuss management plans. Residents receive apprecia ons for good work but more o en end up being scolded for their mistakes and lack of prepara ons during these rounds. As it happens in front of a crowd it is usually an anxiety provoking event.

Grand rounds in psychiatry provide students with a great opportunity to learn from direct observa on of how senior faculty members interact with pa ents and caregivers and how certain discussions are tackled in a neutral and frui ul manner. Students also learn communica on pa erns among colleagues, and get a chance of learning professional e que e through first hand observa on. These are truly invaluable skills in the armoury of any psychiatrist, and if students prepare be er for rounds, the quality of discussions and therefore the amount of informa on gained in each grand round improves manifold.

Relevance of “GRAND ROUNDS”:

(I) Opportunity for the learner to learn.

(ii) Opportunity for the student to learn how to present his case in clinical examina on and how to answer ques ons in viva-voce.

(iii) Opportunity to observe the consultant’s nuances of communica on with pa ent and caregivers. To appreciate the common concerns that they could have and structuring appropriate responses to queries.

(iv) Assurance and confidence to the pa ent (who is the subject of discussion) that the en re team is jointly seeking his welfare.

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(v) As nobody can read everything and face all types of clinical situa ons, joint clinical discussions is an opportunity to widen one’s clinical wisdom.

(vi) More importantly, it contributes to a ‘team-spirit’

Great teachers used to make grand rounds really grand! The interes ng discussions, anecdotes, clear messages, mixed with their experience, humour, and prac cal demonstra ons are remembered by the students for their life me. Popularity of a teacher used to depend on the number of students following the grand rounds. Notes are taken down by students and passed on to a genera on of students as they are ‘pearls of wisdom’.

We should revitalize this once important approach for teaching and promo ng professional development in medicine.

Recommended Reading

Dugdale, A. E. “The Grand Round”. Clinical Pediatrics. 1966, 5(7): 453–455.

Sandal S, Iannuzzi MC, Knohl SJ. Can we make grand rounds “grand” again? J Grad Med Educ. 2013;5 (4):560–563.

Altman LK. The doctor’s world: Socra c dialogue gives way to PowerPoint. New York Times. December 12, 2006.

Weigelt JA. Has grand rounds lost its grandeur. J Surg Educ. 2009; 66(3):121–122.

Hull AL, Cullen RJ, Hekelman FP. A retrospec ve analysis of grand rounds in con nuing medical educa on. J Con n Educ Health Prof. 1989;9(4):257–266.

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PREPARING FOR EXAMINATIONS

Dr. Ajay Kumar
Assistant Professor, Department of Psychiatry, Institute of Mental Health, Agra.
Email id : ajaypgimer2016@gmail.com

Exams in general are associated with an unse ling feeling, pressure of performance and anxiety. In the medical profession, the stress is further enhanced by long duty hours, night du es, high work pressure. Prepara on for examina on demands a dis nc ve approach in medical profession according to the specialty chosen and workstyle of the chosen course.

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A Specialty like psychiatry demands special a en on because of many reasons; the quality of training and method of examina on are not uniform across the country, many centers are unable to meet the recommended standards of training as per Medical Council of India and students are not exposed to various areas in their postgraduate training periods like child and adolescent psychiatry, geriatric psychiatry, rTMS/DBS, consulta on liaison psychiatry, rehabilita on psychiatry, women mental health, forensic psychiatry and psychotherapy. Non-uniform training directly affects the strategy to deal with examina on, and students should assess the weaker areas of training in their ins tute and deal accordingly. In addi on, every student is not the same, one should evaluate his or her weaknesses and work on them.

Know what is expected: The most vital part of the prepara on is to know what you need to prepare and to understand the curriculum. In India, we have MD, Diploma in Na onal Board psychiatry (DNB) and Diploma in Psychiatry (DPM) as postgraduate courses with different curriculum. The MD course is of three years dura on with four theory papers with clinical or prac cal evalua on in the last year as per Medical Council of India. Student should consult his or her mentor to know trends, previous years ques ons and other important areas.

Plan your prepara on: Apart from the training module of the ins tute, students should have a three-year plan (Table 1). Ideally the ins tute should have a curriculum declared and planned it in to the semester system. If this is not the case then student himself can break the whole curriculum in to several parts and set target in six months dura on (Table1). It is advisable to concentrate on psychopathology, phenomenology and diagnos c guidelines during the first six months of the training. Student should hone their skill of history taking and mental status examina on within six months of star ng the course. It is advisable to decide your thesis topic in the first six months. Usually students undergo a rotatory pos ng in various areas, the purpose is to familiarize trainee to all required areas. It is recommended to u lize your pos ngs to hone the skills and acquire knowledge as much as possible during the pos ng in that par cular area.

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Table 1. A sample plan for postgraduates can be modified as per need

First semester

Second semester

Third semester

Forth semester

History taking & mental state examina on

Psychopathology and symptomology

Diagnos c Guidelines: ICD 10, DSM 5

Clinical Psychiatry ll – schizophrenia, affec ve disorders

Basis Principle of Psychotherapy

Clinical Psychiatry lll – anxiety disorders, OCD

Research methodology: basics of sta s cs

Social Psychiatry

Clinical Psychiatry IV – Consulta on liaison psychiatry and psychosoma c disorder

Neuroanatomy and Neurophysiology

Psychopharmacology and Biochemistry

Child Psychiatry

Community Psychiatry and Epidemiology

Clinical Psychiatry Vl – Electroconvulsive therapy, new advances

Forensic Psychiatry

Geriatric Psychiatry

General Psychology: schools of psychology, percep on, a en on, learning, thinking, memory, emo on, intelligence, personality

Clinical Psychology: Intelligence test, memory and cogni ve func ons, Personality assessment, projec ve tests

Fi h semester

Clinical Psychiatry V- substance use disorders, psychosocial therapies, sleep disorder, sexual dysfunc ons

Sixth semester

The new Competency Based Curriculum (CBM) in MBBS men ons about horizontal and ver cal integra on, which are apt & meaningful for postgraduate learning as well. Horizontal integra on means that a student will integrate different learning objec ves that is spread across and is expected to be completed in one academic year, i.e., the student would integrate mul ple topics and learn wherever possible at any given me rather than wai ng ll year end. For example, if a first year PG is expected to learn history taking and mental status examina on (1-3 Months), summary & formula on (4-8 Months), assessment and management (9-12 Months), through horizontal integra on,

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the student would also be able to enumerate the basic principles of management by 4-5 months. Ver cal integra on signifies learning topics of 2nd and 3rd year of postgradua on in the 1st year itself, instead of wai ng for the next phase to begin. For instance, a first year PG would not only learn Fish Psychopathology of emo on, and ICD criteria for depression, but would also touch upon e ology, course and outcome, pharmacological and non pharmacological management when he/she works up a case of depression. Such horizontal & ver cal integra on is expected to provide students with comprehensive learning right from beginning and sharpen the skills by end of the final year.

Students are recommended to start prepara on of academic ac vi es well before me, to prevent from ge ng overworked and also improve your quality of presenta ons. Prepara on of a seminar should start at least two months before schedule. Similarly Journal club prepara on should start two months before. It is recommended to avoid unnecessary leaves during your postgradua on and plan your leave in such a way that you do not lose much teaching classes and academic ac vi es.

Mindset: It is very crucial to maintain a study oriented mindset throughout the training period. To maintain consistency one can try different methods of studying like discussion with friends, wri ng a note or use electronic gussets. One can keep so copies of presenta on and other audiovisual reading material in mobile, tablets and laptops – accessing informa on would be handy. Indiscriminate use of social media, smartphone and internet could be harming and counter-produc ve. One must turnoff of the email,

Keep away nega ve emo on: Medical students are vulnerable for stress and depression which have deleterious consequences. Students must seek professional help if they feel so. One can do several things at the individual level to combat stress and burnout (text box).

Revision and visualize taking test: Reading without revisions go waste, one must make notes which are available for easy reading during exams. For fast revisions, one must learn to make pictorial graphics and algorithms which are easy to revise and remember, and using these in wri en examina ons will fetch more marks . One can also use audiovisual devices wisely. Visualiza on of taking test mo vates and will reduce performance anxiety. Finally, it is preferred to be updated with the latest findings and to answer accordingly, and therefore a quick look at recent ar cles and incorpora ng them in your answers would gain you brownie points in the examina ons.

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Individual strategy to prevent
stress and burnout

A tude and perspec ve:

maintaining interest, developing self-awareness and accep ng personal limita ons.

Building up resilience:

enhance ability to bounce back from stress.

Balance and priori za on

Prefinal exams are usually based on the final examina on format, and are usually held a few months before the actual ones. They aid in sensi zing the student to the kind of ques ons which may be expected, and also about the kind of answers which evaluators expect. It helps the student to prepare in a focused manner in the me preceding the exam, thereby increasing the efficiency of prepara on. It also assists in developing me assessment, and helps students me themselves while answering, which provides a major advantage when there are mul ple essay ques ons, which is o en the case in a psychiatry MD theory paper. It also helps to reduce students’ apprehension about facing the exams. Doing this on an annual basis will assist in building up examina on-oriented learning alongside clinical based learning.

Recommended Reading

1. Chandran S, Kishor M. Depression in Doctors – “ Unsaid , Untold , Unexplored.” 2017;3(2):1–4.

2. Firth-Cozens J. A perspec ve on stress and depression. In: J,Cox, Jennifer King, Allen Hutchinson PM, editor. Understanding doctors’ performance [Internet]. United Kingdom: Radcliffe Publishing, 2006; p. 175. Available from: h ps://books.google.co.in/books?id=bJ4cvpONJq4C&printsec=frontcover#v=one page&q&f=false

3. Grover S, Sahoo S, Srinivas B, Tripathi A, Avasthi A. Evalua on of psychiatry training in India: A survey of young psychiatrists under the aegis of research, educa on, and training founda on of Indian Psychiatric Society. Indian J Psychiatry. 2018;

4. Siddiqi N, Jahan F, Moin F, Al-Shehhi F, Al-Balushi F. Excessive use of Mobile Phones by Medical Students: Should Precau ons be Taken? Biomed Pharmacol J. 2017;

5. Weinger MB, Ancoli-Israel S. Sleep depriva on and clinical performance. Journal of the American Medical Associa on. 2002.

6. Klein G, Driskell JE. The Effect of Acute Stressors on Decision Making. In: Stress and Human Performance. 1996.

7. Wentzel D, Brysiewicz P. The Consequence of Caring Too Much: Compassion Fa gue and the Trauma Nurse. J Emerg Nurs. 2014;

 

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THE IMPORTANCE OF MEDICINE IN PSYCHIATRY

Dr. Najla Eiman, MBBS, MD, PDF(Neuropsychiatry)

Consultant Psychiatrist, Chandigarh Email id : najilaeiman2017@gmail.com

Psychiatry is a branch of Medicine that deals with origin, diagnosis, preven on, and treatment of mental disorders. Psychiatry is one of the disciplines in medical sciences dealing with those condi ons whose causal and remedial factors involve the interface between the organic and the psycho-social. Broadly classified into a Psychodynamic Psychiatry and Biological Psychiatry, this field has over me dis nguished itself as an independent study with an increasing number of young medical trainees op ng for it. Psychiatry has also experienced the emergence of mul ple sub- speciali es within it like Deaddic on Medicine, Child Psychiatry, Consulta on Liaison Psychiatry, Geriatric Psychiatry and so forth. With such ramifica on of the field it becomes even more relevant that trainees even in sub-speciali es stay grounded to their parent branch. A holis c knowledge imparts a trainee an ability to prac ce his/her speciality efficiently as well as interpolate it against a background of General medicine.

Psychiatric and physical illnesses are inextricably interlinked and a poor health status in either domain increases the risk of illness. It is worthwhile to note that physical disorders are present in atleast 50% of psychiatric pa ents and these are o en under recognized and sub op mally treated. The reasons can range from inadequate medical skills to the blindsided perspec ve of an expert that may wrongly lead to premature diagnos c closure.

The unusually high concordance between medical and psychiatric illnesses can be influenced by several factors which include:

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A

Physical ailments occurring as consequences of Mental illness:

• • •

B

Eg: Nutri onal deficiencies in pa ents with chronic mental illness. Blood borne infec ons in subjects with intravenous drug use. Hepatobiliary complica ons with alcohol use etc.

Side e ects arising due to Psychotropics:

 

Extrapyramidal symptoms seen with an psycho c use.
Metabolic syndrome that can appear with use of Second Genera on fg gf hj



sdff dsfAn psycho cs.

 

• • •

C

• • • •

D

Endocrine abnormali es like hyperprolac nemia, hypothyroidism etc. Arrhythmias and ECG abnormali es.
Drug erup ons and blood dyscrasias that can occur with an convulsants etc.

Acute medical and surgical emergencies arising in psychiatric patients:

Acute laryngeal dystonia that can occur as a part of drug induced EPS. Seizures precipitated by clozapine use.
Ventricular tachycardia leading to cardiac arrest.
Delirium tremens etc.

High incidence of comorbidities

   


vccbvb Complex par al seizures.

E

• • •

Pa ents with bipolar disorder o en are found comorbid for Migraine and High incidence of HIV in Bipolar disorder.

Organicity presenting as psychiatric symptoms:

Hypothyroidism mimicking clinical depression.
Parkinson’s disease presen ng with subtle behavioural and mood changes. Behavioural changes noted in autoimmune and infec ous encephali s etc.

  

Hence it becomes necessary for psychiatrists to maintain their confidence in contemporary medical knowledge and skills for a be er pa ent care.

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Certain skills that are required for a psychiatry trainee to develop include:

Elici ng medical history and a thorough clinical examina on: Eg. Neurocutaneous markers can be missed out easily if clinical exam is inadequately performed, signs of Liver failure are to be looked for in every pa ent with alcohol use.

Knowledge of relevant inves ga ons: These may be indicated primarily to establish a biochemical and haematological baseline prior to ini a on of psychotropics, and may be tailor made depending on the need. For eg: To rule out organic causa on, assessing comorbidi es, monitoring for side effects, assessment for blood drug levels in Lithium, Carbamazepine, Valproate, Clozapine.

Basic training in Neuroradiology and Electrophysiology: A trainee should be able to read a normal radio imaging film and also to pick up common neuropathology findings like infarcts and bleeds, cor cal atrophy, ventricular dilata on, aberra ons in basal ganglia, space occupying lesions etc. A basic understanding of the EEG is also essen al in differen a ng normal from abnormal recordings and iden fica on of seizure ac vity and discriminate artefacts.

Training that focuses on iden fica on of medical/surgical comorbidi es and complica ons: This becomes extremely important in the geriatric popula on and pa ents with chronic mental illnesses. The commonest medical comorbidi es include Diabetes Mellitus, Hypertension and dyslipidemia. A concurrent medical management is required in a majority of psychiatry pa ents.

Need for management of common medical ailments and medical emergencies:

Cardiopulmonary resuscita on is a vital skill for every medical trainee. Psychiatrists need to be adept with management of status epilep cus, Neurolep c malignant syndrome, serotonin syndrome, catatonia and medical emergencies like cardiac arrest and airway obstruc on etc. A psychiatry resident is expected to ini ate basic management and make the appropriate referrals or shi to the emergency department depending on the need.

A high index of suspicion for Organicity: An organic disorder can very closely resemble a psychiatric disorder and a keen clinical acumen is needed to separate them. A pa ent with an established panic disorder can present with an acute coronary syndrome which may be misregarded as a panic a ack. Similarly true seizures can also coexist with dissocia ve seizures.

Need for prompt consulta on with other speciali es: Not every medical/neurological presenta on can be managed by the psychiatry resident and here arises the need to make prompt referrals to other departments with clear communica on and follow up.

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To summarise…

Recommended Reading

Pa ern matching skills: One of the ways to differen ate between an acute pulmonary embolism, a myocardial infarc on, and a panic a ack is to see every possible varia on of each of them. This visualiza on, observa on and recogni on of pa erns will make your chance of making the correct diagnosis much greater than a person who has read about it in a book.

Psychiatry training should not lead to a tunnelling of vision at the expense of pa ent care and both medical and psychiatry departments should work in liaison for holis c pa ent care. A psychiatry training that empowers a trainee to form an effec ve and comprehensive management plan for pa ent addressing the physical comorbidi es is the need of the hour.

Manu, P., Suarez, RE, Barne , BJ. Handbook of Medicine in Psychiatry. WashingtomDC AmericanPsychiatricPublishing,Inc;2006.

Kaufman, DM. & Milstein, MJ. Kaufman’s Clinical Neurology for Psychiatrists: Seventh Edi on. Elsevier Inc; 2013.

 

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DOING RESEARCH AND PUBLISHING

Dr. Suhas Chandran

Assistant Professor,
Department of Psychiatry,
St. John’s Medical College Hospital,
St. John’s National Academy of Health Sciences, Bangalore

Email id : suhaschandran90@gmail.com

The truly extraordinary thing about research lies in the thrill of discovery, and the sense of achievement experienced a er reading the final edit of the manuscript. The Indian Medical Educa on Curriculum, however, had been giving minimal importance to research work, and most of the work which was conducted s ll remains unpublished. Nevertheless, there has been a paradigm shi in the a tude towards research, as more ins tu ons are making it a mandatory part of the curriculum and much importance is being given to research experience in recruitment of candidates for academic posi ons. A larger amount of financial support is also being provided to deserving applicants, and it is ideal for postgraduate students to begin their research careers now, when the environment is increasingly becoming more conducive.

Research is not necessarily a ‘primary ac vity’. It is an advanced stage of a more primary or fundamental human nature, namely curiosity and enquiry. In the bargain, man acquires knowledge, which ideally, he invests back into his life to make it useful to humanity. Thus, a research ac vity in PGs is meant to re-kindle a spirit of curiosity and enquiry.

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The importance and advantages of research:

Promotes research literacy and helps in learning the following aspects of research:

Research methodology
Ability to search medical literature
Ability to synthesise informa on from raw data Appraising published research
Computer skills like databases and spreadsheets Understanding sta s cs
Future par cipa on as research collaborators

Gains in clinical aspects:

Understanding illness at a more complex level Formula ng pa ent oriented research ques ons Developing area of special exper se
Keeping yourself abreast of recent developments

Personal and interpersonal skills:

Wri ng and presenta on skills
Time management
Gaining confidence in working independently Working as part of a team
Sharing of knowledge and spreading good prac ce

Career prospects:

Improving your Curriculum vitae
Increasing job prospects
Academic recogni on by colleagues and ins tu on

The excitements of discovery, and the feeling that you came up with something which may, at some point of me, translate to actual clinical applica on, and therefore be erment of pa ents.

Research could also nurture the mentor-mentee rela onship, which provides invaluable professional support and some mes psychological and emo onal guidance during your training years.

                        

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Table 1: Common barriers to PG research and possible solutions

Barriers How do we address these issues?

Time constraints:

It is possible to work around it, by maybe alloca ng one evening in a week for research ac vi es.
Not all kinds of research are me intensive. Systema c reviews, meta-analysis, narra ve reviews, case reports and series, are some of them which can be completed in a short while, as there is no hassle of extensive data collec on. Most of these involve synthesising informa on from previously conducted studies.

Instead of looking at research as something you would have to do over and above clinical work, it would help to conceptualise it as a respite from clinical work and an opportunity to flex other regions of the brain, and thus result in a welcome change of pace.

Mentorship and faculty support: You do not really know how to approach faculty, or even decide who to go to for guidance

Approach the senior resident, and find out about areas of interest of different faculty and then approach who best matches your interests.

Poor knowledge and skill in research process: This is due to the minimal exposure you would have had as an undergraduate.

No par cular protocol or organised

Discuss with senior residents, enquire how they went about conduc ng their studies, what procedures were used, such as protocol prepara on, feasibility of data collec on, Ins tu onal Review Board (IRB) approval, and how long each process took. Most faculty and mentors are happy to help streamline your work, and are usually recep ve to new informa on and sugges ons from students.

research module in the postgraduate curriculum: Makes it difficult to streamline the process, and may make you feel as if you’re thrown in the deep end of the pool without being taught how to swim.

Research funding: Opportuni es are not many, and are also not well known or adver sed.

Personal interest in research: You might not have any interest in research whatsoever, and would ask “What if I do not want to do research?”.

Most ins tu ons have funds earmarked for the purpose of research, and approaching seniors would help find out about ins tu onal and other funding, grants and scholarship provisions. You can also directly approach or mail the IRB or IEC for the same.

For students who are not interested in core research, there are always other op ons, scholarly work, such as wri ng review ar cles, book chapters, viewpoints and case reports. These can be taken up once the mandatory original research is conducted.

 

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Table 2: Di erent phases and steps involved in conducting a research project

No. Phases and steps

I Preparatory phase

1 Selec ng a topic

3 Finding a mentor

5 Approval from IRB

II Inves gatory phase

. 1  Crea ng a database

. 2  Data collec on

. 3  Data storage and management

III Synthe c phase

1 Sta s cal analysis

3 Presenta on and publica on

Comments

Draw from own ques ons in your clinical experience. Discuss with peers and seniors

Discuss research, professional and personal interests

Make sure it meets all ins tu onal and ethical requirements before submission

Create informa on documents, and master chart for data entry

Collect accurate data, without fudging informa on

Keep log of problems encountered and solu ons devised. Perform periodic quality checks of collected data.

Find out how to use the so ware and brainstorm with sta s cian about how the data can be analysed.

Present the paper in conferences. Submit the manuscript for publica on.

2 Formula ng a ques on Form a ques on, define popula on, interven on and outcome

4 Crea ng protocol and Consult with experts in that field, and look for exis ng study design databases, think through every step of the study, an cipate problems and prepare alterna ves. Meet sta s cian and determine sta s cal tools which would

be needed.

2 Cri cal evalua on of Understand your results. Compare with exis ng results database and discuss why there are similar or

contradictory results.

4 Reflec on

Reflect on how you could have done things be er or more efficiently.

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The three phases of resident research: How exactly is an actual research project undertaken?

(Modified and adapted from Hamann, et al, 2006)

Remember as a postgraduate

Conceptualize research ideas in close associa on with your own clinical experiences. It is perfectly alright even if your idea is a cri cal perspec ve and conflic ng exis ng literature

Don’t bite off more than what you can chew-Don’t take on too much at the same me. Ensure your primary thesis is not affected due to other project(s). Quality should not be compromised for quan ty.

Tips for publishing:

Why do we write a research paper? To disseminate our knowledge to others and of course, to see our name in publica on. When you submit your manuscript to a journal, the goal is to convince the editor that your paper has a lot to offer, and not publishing, or publishing it in another journal would lead to a significant loss of impact to the journal and a loss of the privilege of reading this paper to the readers. To successfully do this, the manuscript should meet certain standards:

Learn to be precise, concise and logical in your wri ng. Focus on ‘need to know’ informa on more than ‘nice to know’
Ensure that all parts of the manuscript are linked in some way to the aims and findings.

Ensure that you do not have any made up or fudged data. (exposure may lead to discredit of reputa on and even permanent curtailment of career).
Ensure comprehension. Is the paper understandable? A good litmus test would be to give it to a non-specialist in the subject and check if they understood the concepts. Avoid common errors such as poor grammar and punctua on, mixed tenses, not spelling out abbrevia ons, and incorrect table/figure labelling and referencing.

Do not get disheartened if the paper is rejected. It’s an opportunity to improve the quality of the paper by assessing the reasons for rejec on and rec fying the mistakes. Reviewers’ comments are o en the most valuable in this regard. Perseverance is impera ve, revise, re-revise and submit again. Rejec on is an essen al learning experience.

Have you had a ques on you could not find a sa sfactory answer to, even though you asked most of your seniors and teachers? Have you spent hours poring over textbooks and journal ar cles trying to find the solu on? Maybe you could a empt answering the ques on yourself, through your own research project. Yes, research can be difficult, but finding real world answers and solu ons which could have a clinical impact makes it that much worth it.

      

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Recommended Reading

Even a failed research project can be an enlightening experience. It is important not to lose sight of the fact that the research, even if only a small project, could also benefit pa ents by leading to improvements in knowledge about a condi on and its treatments. Par cularly in an age of evidence-based prac ce, even the most commi ed clinician would have to accept that it is research that provides the theore cal base for logical clinical prac ce. Your research is your contribu on to scien fic literature, your unique signature in scien fic legacy. It will outlast you; and you never really know how many people in the subsequent genera ons are going to benefit from your work

Research methods in Psychiatry, Edited by Chris Freeman and Peter Tyrer.

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Psychiatry is not among the most technological of medical special es, yet changes in the techniques have expanded the knowledge and enhanced the diagnos c and therapeu c abili es of its prac oners. Modern Psychiatric diagnosis begins with Philippe Pinel in Paris who in his textbook in 1809 enumerated four Psychiatric diseases- mania, melancholia, demen a and idio sm (Intellectual Disability), what he meant by these has translated into a number of modern illnesses and newer forms of classifica on and novel treatment strategies. Unlike other branches of medicine, treatment of psychiatric pa ents requires a mul disciplinary approach.

In a consulta on liaison scenario – Not all the pa ents who come to the psychiatrist have a psychiatric illness, and a minority of them may have a diagnosable neurological or a general medical condi on. Hence it is the role of the psychiatrist to promptly iden fy, diagnose, treat these condi ons by himself or by liaising with other special es (e.g.- Neurology, Physician etc.). A psychiatrist is also called upon in various medical se ngs in order to treat some of the Common Mental disorders in the medical setup, in emergency se ngs to diagnose and treat delirium (e.g.- Delirium Tremens). Pa ents with terminal illness have high incidence and prevalence of Psychiatric morbidity and Psychiatrists are o en part of the team who deliver pallia ve and end of life care. See as many pa ents as you can see in a number of training se ngs and talk to as many colleagues as possible from different departments. You may have seen a rare presenta on of a par cular disease during your training, which would allow you to pick it up when you see something similar during your independent prac ce.

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MENTAL
HEALTH CARE
IS A TEAM EFFORT

Dr. Naveen Pai *, Dr. Sundarnag Ganjekar **,

*Senior Resident, **Associate Professor, Department of Psychiatry, NIMHANS, Bangalore

Email id : drbsnake@gmail.com

In the emergency department – Psychiatrists o en come across various clinical scenarios like examining a pa ent with sexual abuse or trea ng a homeless mentally ill person in an emergency se ng. It is o en in these situa ons, a psychiatrist may be the leader of the trea ng team or maybe a part of the trea ng team which may include Psychiatric Social worker, Physician, Obstetrician, Forensic Expert and law agencies. When working in a team it is most important to acknowledge and respect others views, values and ideas. Psychiatrist should understand the role of each individual in the team, range of skills of all other colleagues and promote prac cing effec ve team work. It is beneficial to prac ce sound verbal and wri en communica on whenever necessary and to promote interprofessional learning in the work se ngs.

Rehabilita on services – While trea ng pa ents with severe mental illness, during the period of recovery they require more of rehabilita on inputs than acute medical management. The rehabilita on team consists of Psychiatrist, Psychiatric Social worker, Psychologists, occupa onal therapists and psychiatric nurses. Inputs from each person of the team along with a holis c approach covering all aspects of pa ent’s life with the focus on delivering recovery-oriented services is more beneficial than just prescribing medica ons.

Being a team player in rou ne pa ent care – On both the inpa ent and outpa ent side you can delude yourself into thinking that you are func oning independently and that you and your pa ents are in a separate parallel universe. It is not just the pa ent and you who are involved in the therapeu c rela onship. In a developing country like India where the Mental health professionals (MHPs) to pa ent ra o is less than other countries, MHPs o en depend on the families. There is a high need that family members need to be involved in the provision of care. This process not only protects the pa ent’s rights but also gets the family members involved in ac ve treatment processes such as psychoeduca on, supervised medica on, family therapy, to be co-therapist, and also in rehabilita on process. All these make a huge difference in con nuity and outcome of the treatment. Families provide majority of care, and also help in monitoring and managing the illness, maintaining the home, encouraging, socializing, loca ng services and hence play a major role in the treatment of a person with mental illness.

Ontheinpa entside,therela onshipswithnursingstaffarecri cal. Theworstpossible scenario is a resident who develops a comba ve rela onship with nurses and views them ascrea ngextraworkforherorhim. Animportantcomponentofanypsychiatrists’role on the inpa ent side is to make sure that no spli ng occurs and that highly problema c dynamics involving staff and pa ents are avoided.

Working with Mental Health NGOs – Mental Health NGOs are distributed throughout the country, although there are a greater number in urban areas, and in states where there are rela vely lesser pressing problems posed by poverty and communicable diseases

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(for example, southern states). Role of such NGOs, media and the general popula on cannot be ignored in iden fica on and preven on of mental illness. Examples of such NGOs are the Alzheimer and Related Disorders Society of India (ARDSI), which was started in Cochin, and has now spread to more than a dozen centres in India. Similarly, the Richmond Fellowship Society has three centres. The concept of child mental health has broadened from its earlier focus on mental retarda on to include the far commoner mental health problems seen in children, such as au sm, hyperac vity and conduct disorders. MHNGOs such as Sangath Society (Goa) and Umeed and the Research Society (Mumbai) provide outpa ent and school-based services for such problems.

Working in unison with the media – The role of media in promo on and preven on of mental illness cannot be neglected, also educa on of the general popula on about mental illness and allevia ng the s gma and helping persons with mental illness in reclaiming their posi on in the society and leading a be er quality of life. Despite the exis ng mental health policies in India, there is a high treatment gap and there is an urgent need for a Mental Health program that can be implemented in prac ce and can cater to the health needs at all levels of preven on (primary, secondary, and ter ary) while also protec ng the rights of the family, professionals, and end user.

Even the hardest days of residency is made easier by suppor ve colleagues who can laugh and cry together. However, some mes you will have teams that just do not gel. Do what you can to be pro-social: pitch in, adapt and support each other.

While most obvious are the co-residents and interns, ancillary staff from social workers to nursing staff can colour how any given day will go. Never underes mate the importance of establishing and maintaining these rela onships. These folks will go out of their way to help you – or won’t.

Take home message

Team dynamics can make or break your day

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FACING THE FINAL EXAMINATION : WHAT THE EXAMINER EXPECTS

Dr. Alka A. Subramanyam*, Dr. R.M. Kamath**

*Associate Professor,
**Professor and Head
Department of Psychiatry,
TNMC & BYL Nair Ch. Hospital, Mumbai

Email id : alka.subramanyam@gmail.com

The final exam is actually a strategic game plan. If approached diligently and methodically, there is li le scope for much problem. We can divide the approach into theory and prac cal exams.

THEORY:

Keeping the above in mind the first step is the theory examina on. This is usually divided into 3 or 4 papers (depending on diploma or degree courses) –covering basic neuroscience and psychology, psychiatry and recent advances. Some universi es con nue to have an essay ques on in paper 4.

As an examiner for a postgraduate course, the following are the points that an examiner keeps in mind:

Be specific and relevant to the ques on asked.

For eg. Describe the management for a 35 year old woman, diagnosed as a case of depression, who has 12 weeks amenorrhea and wants to con nue to term. What advice on breas eeding will you give the mother?

In the above case, there is absolutely no need to ramble about an -depressants in general, the choice and algorithm for management of depression in general etc. etc. One needs to focus and highlight on depression in pregnancy and lacta on.

Approach the topic in depth

For eg. Neuro-modula on techniques in psychiatry – A simple enlis ng and merely one line on the above cannot suffice. As a postgraduate, you are expected to furnish informa on on at least the level of clinical significance which will aid in pa ent care. Technicali es of techniques are also required, but the emphasis will be on clinical applicability and risks.

 

1

2

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3

Whenever there is a choice, a slightly unusual ques on is given more weightage

4

5

For eg. Answer any one – (a) CBT for OCD OR (b) Metacogni ve therapy.
Very few people may opt to answer (b) instead of (a). However, candidates who know answer (b) well and answer it, may have chances of scoring higher, by virtue of a emp ng an unusual answer and a emp ng it well.

Schedule your me

It is very easy to get carried away in a postgraduate exam and answer everything in depth; as a result one o en runs out of me and does not get me to answer all the ques ons. This can be a fatal error, and hence allotment of me depending on the weightage of the ques ons is a good idea. Examiners cannot allot marks when ques ons are not answered at all.

Use diagrams and flowcharts wherever possible

Representa on of data and thoughts using flowcharts and diagrams always give a clearer picture of what you intend to express par cularly in ques ons pertaining to management, stages, algorithms etc. For eg. RDoc criteria for diagnosis. An examiner will give more weightage to sensible albeit short content, than pages filled with unclear concepts.

Be neat

Completely illegible handwri ng, too large, too small etc. are to be avoided. Any examiner who has to strain for the assessment, automa cally gives lower scores.

Do not conjecture

It is be er not to a empt an answer than to fill pages with just about anything. At a postgraduate level this is absolutely not acceptable. It sends an erroneous message and may affect the examiners overall outlook toward marking the paper.

Write down points as sub-headings and bullets

Presenta on ma ers. Use it to op mize the output and score be er.

Try to s ck to the ques ons sequen ally. Leave space if unanswered.

Itisveryannoyingasanexaminertokeepgoingbackandforthforeg Ans1(b),Ans 3(c), Ans 2(d), Ans 1(a), Ans 1(c), Ans 3(d), Ans 2(f) etc. etc. Preferably s ck to the sequence leaving an cipated space if you don’t know and come back to answer the same.

Essay ques on

For those who have an essay ques on, it is easier to write an index of what you intend to cover, and then approach the answer. Most examiners will assess your depth of knowledge based on your index and presenta on of the same.

 

6

7

8

9

10

   

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PRACTICALS:

This is where even the most robust of candidates turn around and have cold feet. It has been an experience and o en surprise for most internal examiners, when their so called ‘good’ candidates, suddenly fumble in the exam – which is why as much as the exam assesses your ap tude, it also assesses your a tude, and developing the same in very important.

What I have presented below is the MSE of the examinee, from an examiners point of view:

Mental Status Examination of the Examinee

A tude : Confident, humble, don’t fib or ramble.
Appearance : Well groomed-formal clothes, apron, roll no. tag, nails well cut, clean

shaven, hair well cut/ ed back.
Behaviour : Modest, don’t argue though defend your diagnosis and management.

Conscious : Most important rule in the exam. Sleep well. Falling asleep or yawning in front of the examiners makes a bad impression.

Co-opera ve : Be flexible. Sway to the tune of the examiner. Don’t get fixed with your ideas.

Communica ve : If you don’t talk, you can’t score!! Prac ce the art of presen ng cases and post-OPD’s from the 1st post itself. Ask ques ons. Seek answers.

Eye-to-eye contact : Maintain eye contact with your examiners. Don’t avoid gaze of the examiner especially when you don’t know a ques on. Say “I don’t know” looking at him/her in the eye. It makes a be er impression

Rapport : It is very important that you strike a chord with your examiners. You must not appear too anxious, nor over confident and cocky. Examiners want to pass a candidate who they are confident can go out in the world and tackle pa ents adequately – who is not too theore cal, nor too experimental.

A en on : Pay a en on to what the examiners are saying. O en, due to our anxiety we don’t hear their line of ques oning. Also, keep your ears open for any ps/hints. Be quick to answer, don’t go round and round, especially when asked to stop with one line of thought.

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Mood:

Subjec ve : Be amiable, don’t argue, and don’t go on the wrong foot. Don’t believe “S/he is a terrible examiner” If that’s true, it’s true for everyone. Some amount of anxiety is op mal, gives a be er performance.

Objec ve : See the mood of the examiner, and change yours accordingly. Don’t antagonize him/her unnecessarily.

Affect : Maintain a balanced affect throughout. Acute change of facial expression especially if there is an error, crying, too much emo on etc. all go against you.

Thought : It is impera ve that along with your pa ence you are also con nuous, coherent and relevant. Answer what is asked, and not what you know. Don’t mumble. Be clear and precise. Avoid delusions of persecu on. No examiner is out to fail only you. When examiners are laughing with each other, they have just cracked a joke!! They are not laughing at you. Don’t become referen al. Exams are a phase. Don’t become obsessed with metables/por ons etc. Don’t let compe on become unhealthy so that you become homicidal/suicidal. Enjoy the process of learning. The gold medal is temporary. Your pa ents will be the ul mate test. IF they come back to you, you’ve been successful in the exam called LIFE.

Concepts : If you don’t read, you can’t pass. Examiners know those who have depth of reading. Your concepts both simple and complex have to be very very well grounded. READ, READ, READ. This should be a habit, daily, so it doesn’t pile up in the end. This is tested across the cases, examina on both physical and mental, and in depth in the viva.

Percep ons : Don’t imagine things that do not exist. If you hear things that are not true, and see things that don’t exist, the stress levels have reached detrimental levels, and you may need to seek help. Sleep well, use less caffeine as this may cause more harm in the long run.

Orienta on : Due to the long preparatory leave, you may forget the date, day etc. make sure you have a support system and reminders for the day of the exam, centre etc. Also, you should be well versed and oriented to the news-at least the basics. Your examiners have studied 15-20 years before you; they will ask ques ons more per nent to contemporary issues.

Memory : What helps in the exam finally is the LTP- long term memory. So from Day 1, start preparing good histories, discuss cases, management etc. Keep reading relevant literature on a case to case basis; discuss cases with your seniors and contemporaries. Prac ce talking about drugs, MRI’s, CT’s, EEG’s etc. In your daily work organize things the way they would be for the exam. That way you don’t have to make an effort at the last minute – there will be no “exam history and exam management” and “normal history and normal management”. As a result, it becomes a rou ne habit.

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Judgment : Use your judgment and review the last 5-10 years papers to see what the expected ques ons are this year. Further, also find out a bit about your examiners-their areas of research, what they’ve worked in etc. Read up those topics in addi on to the general ones. It may give you an edge.

Intelligence : World over, we now know that success is related more to EQ than merely IQ. Equip yourself with knowledge (There is no shortcut to that. Hard work pays) and combine it with the right a tude, it gives a winning formula for success.

General Fund of Informa on : It is impera ve that you know a bit of general medicine and of course neurology, for your exam. You can’t isolate knowledge or compartmentalize it. O en, psychology as a chunk is ignored or kept ll the end. This is mostly because we don’t really understand psychology, or discuss it. In the viva, anything can be asked. Have regular discussions in this format at your place of learning. It really helps!

Insight : Have the insight to know when you’ve gone wrong-backtrack and correct yourself. Be aware that unnecessary arguments can be fatal. There’s a fine line between defending your point of view and arguing. Learn that. Failure is the stepping stone to success. Learn from failure, don’t succumb to it. Finally, the exam is just an interim phase; the real test lies in the outside world which is wai ng for you to make your mark. If not this me, then a er six months, you have to go out and seize that world! No big deal. No pa ent asks how many a empts you have had. Once you get in, you have to get out.

REMEMBER THAT APTITUDE AND ATTITUDE BOTH MATTER! GOOD LUCK!!

Recommended Reading

Guidelines for competency based postgraduate training programme for MD in Psychiatry-Medical Council of India accessed from h ps://old mciindia.org on 15th July 2019
Sharma S. Postgraduate training in psychiatry in India. Indian J Psychiatry. 2010;52(Suppl 1):S89–S94. doi:10.4103/0019-5545.69219

  

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Dr. Pratima Murthy

Professor and Head, Department of Psychiatry, NIMHANS, Bangalore

MENTORSHIP IN PSYCHIATRY

Email id : pratimamurthy@gmail.com

Introduction

The word ‘mentor’ has its origin in the Greek Odyssey where Mentor was a friend of Odysseus. When Odysseus le for the Trojan War, he is said to have le Mentor in charge of his son Telemachus. Mentor’s name has been adopted in various languages, including English as a term meaning someone who imparts wisdom to and shares knowledge with a less experienced colleague. A mentor has been variously defined as “a wise and trusted teacher or counselor”, “an experienced and trusted adviser”, “a person who gives a youngerorlessexperiencedpersonhelpandadviceoveraperiodof me”. Mentorship has been defined as a process whereby ‘an experienced, highly regarded, empathe c individual (the mentor) guides the protégée (mentee) in the re-examina on of their ideas, learning, personal and professional development’.

Mentorship has been used in a variety of educa onal, workplace and social se ngs.

Why have a mentor?

Professional and personal growth and success are generally universal aspira ons. This can be nurtured by someone who can advise, who can mo vate and challenge you towards greater achievement, who is vested in your interest and a person you can turn to in difficult mes. “If I have seen further than others, it is by standing on the shoulders of giants.” These words of Isaac Newton possibly sum up what a mentor can do.

Who is a mentor?

The a ributes of a mentor are summarized below

Attributes of a mentor

Is available and gives me to mentorship

Is invested in mentee’s success

Has mentee’s interest at heart

Supports, mo vates, guides, challenges, advises and provides cri cal appraisal

Serves as a good role model
Shares life experiences that are mo va onal

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What mentorship is not

O en, mentorship is confused with teaching or supervision, or even with coaching or counselling. A mentoring rela onship is informal, less structured and more in mate than a formal teacher-student rela onship. Mentoring is usually a one-to-one rela onship. While supervision is more task-oriented, mentorship seeks to be more reflec ve on larger perspec ves. Mentorship is also different from counselling, which may look at the dynamics of underlying conflicts and their resolu on. An analogy can perhaps be drawn from the Sanskrit terminology of various kinds of teaching, from the Shikshak, Adhyapak, Upadhyay, Acharya and Guru.

Kinds of mentorship

As the concept of mentorship has evolved in various fields, the no on has expanded to different contexts. Mentorship could be natural, where one person, usually a senior, reaches out to another. It could be trainee- led, when the trainee approaches a poten al mentor. It could be peer mentoring where individuals are at the same level, with one assuming a mentorship role. Peer mentors can be important to help entrant trainees to navigate their new professional environment, build a sense of community and develop support networks.

In more recent years, in diverse fields from sports and workplaces to educa onal se ngs more structured mentoring programmes have evolved that match mentors and mentees- this is a form of formal mentoring.

Relevance of Mentorship in psychiatry

As in many other fields of medicine, training requires a well-structured and supervised programme. Trainees in psychiatry have unique challenges – pa ents are likely to be complex. In addi on to knowledge, skill and understanding, emo onal robustness is also an important a ribute in dealing with challenging pa ents. Greater stress, more isola on and perhaps a mis-placed belief on exclusive self-reliance are serious challenges for a new resident. Having someone to turn to, not just for career development, but also to enhance problem-solving skills, develop professional a tudes, responsibility and integrity and to develop a good work-life balance are all very cri cal parts of the forma ve training.

Mentoring programmes in psychiatry

Several ins tu ons in the USA, as well as the UK, Australia and Canada run formal mentorship programmes. The American Psychiatric Associa on offers formal mentorship experience. Many psychiatric training programmes offer residents a faculty ‘point person’ to whom they can turn to for advice and support throughout their training. These mentorship programmes are designed as ac ve and dynamic processes that require the mentee to engage and invest me and energy. While the ini al mentor is ‘iden fied’, it is an cipated that subsequently, residents may develop new mentorship rela onships as their career progresses and aspira ons and direc ons change.

   

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Some of these mentorship review programmes are evaluated on a regular basis by both mentors and mentees.

What attracts mentors to mentoring?

Many professionals, par cularly those who have many years of experience, like to provide the encouragement and direc on to trainees in the beginning of their career. Effec ve mentors con nue to reach out, provide encouragement, take pride in the mentee’s accomplishments and con nue to provide support in mes of need.

Challenges to mentoring

In many se ngs, lack of professionals with mentoring skills, bad experiences with mentors, lack of me on the part of the mentee and mentor can pose challenges to mentoring rela onships. Technology has, however made it possible and much easier for con nued communica on, even when regular face to face contact may be difficult.

Is mentorship relevant only for trainees?

Not really! Mentors are important, not just at the beginning of one’s career, but throughout it. Mentors can also be very useful in advising for professional growth and making choices; crea ng work-life balance; at the me of entry into a consultant’s posi on; at the me of discharging onerous responsibili es in senior posi ons; perhaps even in ge ng post-re rement advice from a mentor who has been through that phase as well !!

Mentorship without boundaries

Wri ng about mentors cannot be complete without the men on of some exemplary mentors who have made mentorship of young psychiatrists around the world a passion and a mission. Professor Norman Sartorius, along with Professor Mohan Isaac have been involved in training young mental health professionals all over the world and exemplifies the ideal mentor of young mental health professionals.

Take Home Messages

A mentor is an individual who provides professional and personal guidance to a mentee and can be invaluable both at the beginning of one’s professional life and throughout it.

Mentorship can happen through formal programmes, or natural selec on which may be mentor or mentee-led. The special challenges in psychiatry makes mentorship par cularly useful.

    

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Recommended Reading

Byyny RL. Mentoring and coaching in medicine. Editorial. The Pharos/Winter 2012. h p://alphaomegaalpha.org/pharos/PDFs/2012-1-Editorial%20.pdf

Hameed Y, De Waal H, Bosier E, Miller J, S ll J, Collins D, Bennet T, Haroulis C, Hamelijnck J & Gill, N 2017. ‘Using mentoring to improve the founda on placement in psychiatry: review of literature and a prac cal example’ Bri sh Journal of Medical Prac oners, vol. 9, no. 4, pp. a932.

Lau C, Ford J, Van Lieshout RJ, Saperson K, McConnell M, McCabe R. Enhancing mentorship in psychiatry and health sciences: a study inves ga ng needs and preferences in the development of a mentoring program. Mul disciplinary Scien fic Journal. http://www.mdpi.com/journal/jjournal J 2018, 1, 8–18; doi:10.3390/j1010003

  

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DEALING WITH CRITICISM AND DIFFICULT PEOPLE

While working in a team, it is quite common to receive feedback or cri cism from the client, colleague or the superior. Although the word ‘cri cism’ invariably carries a nega ve no on to be a judgmental or a fault-finding act, it can be divided into two major types – Construc ve cri cism & harmful cri cism. Construc ve cri cism – as the name suggests, is designed not only to point out one’s mistakes, but also to show where and how improvements are possible. Construc ve cri cism can be viewed as a useful feedback that can help one introspect and improve self rather than feel insulted or humiliated. On the other hand, harmful cri cism may result in reducing self-esteem, cause anxiety, depression and/or lowered work efficiency. A constant nega ve feedback can disengage person from the work mo va on.

One should try to receive the cri cism tac ully so that it doesn’t damage the self-esteem. Following strategies (LAUGH) can help to deal with cri cism:

Listen : Be available to receive cri cisms. Different people can have different a tude towards you. Respect the observa ons others have made about you. Try to remain calm while receiving cri cisms and refrain from counter-cri cism as it may result in anger and resentment. Take me-out from the situa on if the cri cism becomes extremely nega ve, personally a acking or distracted from the focus.

Assume good inten on : Most of the me, a feedback or cri cism has some fact in it. Even if it doesn’t sound right to you, try not to be judgmental and think about it later in a neutral manner.

Dr. Shubhangi Dere, Assistant Professor, Department of Psychiatry, MGM Medical College, Navi Mumbai.

Email id : shubhangi.dere@gmail.com

 

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Understand that you are a fallible human being and can commit mistakes. Do not let cri cism influence your self-esteem and confidence. Introspec on is an important key to improve. Try to get mul ple perspec ves for your behaviour which can help you to understand yourself be er in a non-threatening manner.

Cri cism as a Gi : Remember, cri cisms can be a gi to yourself. A mely, well- received cri cism can make your life. Cri cisms can provide opportunity to change a er all.

Help yourself : Iden fy triggers of you landing up in trouble. If its related to your short- comings like punctuality, lack of skills, inability to express, poor coordina ng abili es, or poor follow-up, try to improve with insights received. Refrain from becoming defensive or excusing yourself with reasons. At the same me don’t be too hard on yourself. Improve self-talks. Statements like ‘I’m a failure’, ‘its my fault only. Others are too good unlike me’, ‘I’m insulted in front of everyone… that’s it…can’t take it anymore’ can result in arbitrary, faulty evalua on of self and can lead to extreme behaviour like isola on, avoidance or self-harm.

A healthy, comfortable team rela onship and coordinated efforts are the keys to success:-

Specific to the hospital setup, there are certain other situa ons which you would come across on a daily basis, such as being shouted at by seniors, consultants who have their own preferences of presenta on styles and so on. Instead of taking it personally, correct yourself and take it as a chance to step up your game. If you have made a mistake, own up to it and rec fy it immediately. This lets your superiors know that you are genuinely concerned about your pa ents and are learning from your mistakes. A par cular cri cism may not come across as construc ve, and it depends on you to find out how you can benefit from it and pick out learning points so that you make it construc ve to yourself.

Most of us want people to like us, and prefer not to get into conflic ng situa ons. As a resident, you are constantly trying to meet the needs and expecta ons of a whole cast of characters – consultants, senior residents, nurses, medical students, pa ents, caregivers, even your co-residents and juniors. At mes, what they want you to do will be diametrically opposed to each other. Difficult interpersonal situa ons and conflicts can arise in almost any circumstance.

Handling difficult people at the workplace is a challenging task and may result in workplace tension, harassments or absenteeism. Being part of a team takes effort, where you need to be part of the team and some mes may also have to take the lead. You may need to help your peers focus, and when not possible, func on past them and focus on your own goal despite setbacks. Confronta ons are frequent and you need to learn to communicate effec vely to resolve conflicts.

  

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Building up mature defence mechanisms such as suppression, an cipa on, humour, altruism or sublima on is necessary to prac ce and apply effec ve coping strategies. For example, someone who an cipates a difficult situa on would be be er able to cope with it by making a plan to solve the impending problem beforehand. Humour can also be an effec ve way to reduce tensions when used appropriately.

In interac ons with seniors, it is important to maintain a deferen al a tude and put across your views without seeming to impinge upon theirs. It is also important to know when to back off and not become argumenta ve. While dealing with colleagues and juniors, always communicate your ideas without being condescending, and consciously stay away from accusatory tones. The thumb rule here is to talk to them they way you would want others to talk to you. With pa ents and caregivers, it is always best to be respec ul and address their needs adequately. If in spite of doing things right, you are s ll found fault with, it is be er to ensure your own safety, both professional and physical. Always ensure detailed documenta on, keep your superiors informed and seek help when needed to handle such situa ons. When it comes to issues such as ragging or sexual abuse, do not hesitate to speak to someone you trust and escalate the ma er to concerned authori es such as the an -ragging commi ee of your ins tu on.

To conclude consider the following truisms:

“All learning is trial and error learning” and “To err is human”
“Truth hurts but does not harm. It is a gift”,
“Whatever happens, learn something useful from it”,
“Irrespective of the nature of criticism, positive or negative, learn to bear it and develop resilience “and “whatever happens, strive to maintain a cordial relationship”

Recommended Reading

h ps://www.mindtools.com/pages/ar cle/UnfairCri cism.htm

h p://gmj.gallup.com/content/124214/driving-engagement-focusing- strengths.aspx

h ps://dmh.mo.gov/dd/docs/ eredsupportsummarythesandwichmethod.pdf De Leon J, Wise TN, Balon R, Fava GA. Dealing with difficult medical colleagues.

Psychotherapy and psychosoma cs. 2018;87(1):5-11.

   

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THE IMPORTANCE OF ONE’S FAMILY

“Family is a life jacket in the stormy sea of life”

– J.K. Rowling

Prof. S.M. Manohari

Professor and Head,
Department of Psychiatry
St. John’s Medical College Hospital,
St. John’s National Academy of Health Sciences, Bangalore.

Email id : manohari.sm@stjohns.in

  

Postgradua on happens at the stage of in macy verses isola on of Erik Erikson’s epigene c principle. The postgraduate’s role as the indulged and looked a er child in the family who needs to be doing his/her obliga on of studying and being “good” slowly transforms.Nowthechildisanadultwhohastoprovideemo onallyandfinancially. The skillofdealingwiththeresponsibilityoflookinga erothersisnotalwaysinnate. Many postgraduates also enter into commi ed rela onships and marriages which means another family is added by law. Some postgraduates also become parent’s themselves.

Postgradua on is a period of intense learning, with a work schedule that is daun ng. Life cannotbecompartmentalizedwitheachpartfollowingtheother. Everythinghappensin parallel. Given this situa on, the student needs to learn to use family as the anchor in this notnecessarilyalwaysaturbulentphaseoflife. Youneedtorememberthatmanya me

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familybecomesabaneratherthanaboon. So,howcanthestudentmakethebestofthis situa on? First thing to remember is that there is no hard and fast rule and only general principles that will help understand and cope with your changing roles.

O en the PG student is the only doctor in the family as well as in the social circle. So, from trea ng colds to giving second opinions, of which you are very unsure off, becomes your reluctant job. A ending to sick family is also important. Here, your role as a family member being available during the rounds/feed-back session of your family, rather than being a care giver may be be er use of your abili es. The skill of delega ng responsibili es is important here. Rou nes at home involving house-keeping ac vi es like cleaning, cooking, etc are essen al, but does eat into your me to study, in being punctualatworkorgiveyour metointeractwithfamily. Learntogentlynego atewith family, in laws and spouse so the work is shared and/or domes c help is appointed.

Visi ng family, ge ng involved during fes vals or func ons along with managing your duty hours, on call work, mee ng deadlines for presenta ons, thesis etc is always a challenge. Learning to be organized and planning in advance will help. Also, when you help a co-student, they will also help you out in exchanging du es etc.

For students who are parents, the child/children cannot be ignored, during your PG period. At the same me your career cannot be given up. Using a crèche or babysi ng facility is not harmful for the child. Ask for help when you need it. Others cannot read your mind or know that you are struggling. If you feel like you may benefit from medica on or therapy yourself, do not feel ashamed, do not hesitate to seek help. You are en tled to the same treatment that you offer your pa ents. In the end, it’s you and your family who is going to lead a be er life. Learn to communicate your difficul es effec vely. Learn to priori ze. Havefunwithfamily. Thisisalsoimportant. Behappytohaveafamilyandgive as much as you can to get all you want.

To summarize

Learning to communicate with family (including parents, sibs, spouse, inlaws, children and the whole extended Indian family) is an essen al skill. Be diploma c, have emo ons in control and learn to say no when needed.

Learn to priori ze.

Learn to delegate – especially tasks which do not require your exper se. Try to be organized and plan ahead of me.

What I have put down here is in hindsight! I wish I had used some of these skills when I was a PG.

  

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THE THINGS THAT ONLY PATIENTS CAN TEACH YOU

Dr. Nilesh Shah

Professor and Head,
Department of Psychiatry,
L. T. M. Medical College and General Hospital, (Sion Hospital), Sion, Mumbai

Email id : drnilshah@hotmail.com

My first day in the psychiatry outpa ent department:

She was my first pa ent; an 80-year-old, Nargis Banu, clad in a Burkha. “…तु ा तकलीफ है ? (What is your problem ?), I asked hesitantly. She stared at me for a while and then started

crying. “…डॉ र साहब …आपक उ के म रे बेटे हlै आज तक क सी ने मुझे ‘तुम’ नह कहा है (Doctor, I have

sons who are of your age, ll now no one talked me by saying “you”) I learned my first lesson of communica on skills from my very first pa ent on the very first day of my residency; ini ate communica on with ‘आप’ (you).

Pa ents and their rela ves don’t read psychiatry books:

A couple of months down the line, I realised that pa ents and their rela ves don’t read psychiatry books prior to seeking consulta on. Many symptoms men oned by the pa entsarenotmen onedinthebooks.“…मीठा-मीठादद” (sweeterpain),“…ऊपरकासांसऊपर

,नीचे का सांस नीचे (breathlessness)”, “…ह ी का बुखार (Fever in bone) ”. I quickly learned the new vocabulary from my pa ents and the vernacular equivalents of the disease specific

symptoms given in the books.

The body language:

Soon, I realised that I must pay lot of a en on to non-verbal communica on; what is said and how it is said; I started focusing on their body language and gestures. Had read about elated mood, flight of ideas, depersonalisa on, derealiza on but only while interac ng with the pa ents, I understood the real meaning of these words. I started apprecia ng the difference between informa on, knowledge and experience.

…मेरा Sunday कहां गया (Where is my Sunday ?) 50

A pa ent whom I had prescribed Tab clomipramine (10 mg) at bed me on Saturday came to me on Monday morning and caught me by my collar; “…मेरा Sunday कहांगया …”; he was

very annoyed as a er taking clomipramine 10 mg on Saturday night, he had slept for about 36 hours and only woke-up on Monday morning.

My seniors and teachers reassured me and explained that each pa ent is different; the effects and side-effects of medicines may also vary from pa ent to pa ent depending on whether they are slow or fast metabolizers; everything may not be there in the books and journals; keep your eyes, ears and mind open; do not miss any opportunity to learn from the pa ents. One size doesn’t fit all.

There are pa ents who may have exaggerated reac on to anything and everything and may request a pill for each symptom while at the other end there are pa ents who are quite resilient and face the situa on with courage and determina on. There are pa ents who may need lifelong treatment and there are pa ents who may recover spontaneously without any interven ons. Many such things one learns from the pa ents by regularly following them over a good length of me.

Accolades and brickbats:

Pa ents and rela ves come up with many original innova ve ideas in group therapy mee ngs, care giver’s mee ngs and alcoholic anonymous self-help group mee ngs. Some examples are, How to deal with the challenging behaviours of senior ci zens having demen a or intellectually disabled child, and How to control craving and stay away from drugs and alcohol, using paradigm of ‘one-day-at-a- me’.

The original innova ve ideas and cri cal observa ons:

It is very important to get a feedback of your treatment from the pa ents and their rela ves. ‘…आप हमारे भगवान ह…ै ” to “…Can you please refer us to some senior and more

competent and experienced doctor?”. Many finer intricacies of treatment and management are learnt in this way.

Don’t be an overprescriber :

When learning psychopharmacology, it is temp ng to consider pa ents to be constella ons of biologically treatable syndromes, but there are certain problems with this approach. First and foremost is the inability to recognize the problems in the context of a comprehensive formula on of the pa ent’s temperament and personality. There may be other logis cal issues due to which the pa ent may not be able to maintain compliance, or may have unacceptable side effects. It is important to tailor your approach

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to the pa ent and his en re psychosocial context, and choose a combina on of pharmacological and non-pharmacological treatment as required in the par cular situa on. In many cases there is a feasible psychotherapeu c approach that is comparable with medica ons and it has fewer side effects.

To be or not to be:

“…Doctor, is it okay if I don’t tell the prospec ve groom and in-laws about my daughter’s psychiatric disorder?”; “…Can I give disulfiram to my husband without his knowledge?”; “Please make him unfit, so that our son will get a job in his place”. “…My wife is of loose moral character, has many extramarital affairs, can you arrange to pick her up forcibly in an ambulance and put her in a rehab centre?”. We face number of such social, moral, legal, ethical dilemmas in our day-to-day clinical prac ce. The opinions and guidelines on how to deal with these situa ons may differ. Every me depending on the happy or sad outcome of the problem one more lesson is learnt. The lesson which only pa ents can teach you.

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DEALING WITH BURNOUT IN PSYCHIATRY RESIDENCY

Introduction :

Dr. Sandip Deshpande Consultant Psychiatrist, Sexual & Relationship therapist People Tree Maarga, Bangalore

Email id : docsandypande@gmail.com

Medicine as a profession is a stressful one. It has become more demanding and this can put pressure on the clinicians. One of the outcomes of this is burnout and emo onal impact on the clinicians. Burnout was originally thought to happen a er many years of medical career, but, is now being described even among medical students. This ar cle looks at burnout – its causes, manifesta on and ps and tricks to deal with it – with a special emphasis on psychiatry trainees.

Burnout : what is it?

The term “burnout” was first used in a clinical sense by the psychologist Herbert Freudenberger, in 1974 who described it as par cularly per nent to professionals who wereinthebusinessofcaringforothers. Insimpleterms,itcanbedefinedasastateof chronic stress that contributes to emo onal and physical exhaus on and detachment.

The world health organiza on (WHO) has proposed to include Burnout as a category in the Interna onal Classifica on of Disease, Eleventh Revision (ICD-11) which is due to be released in 2022. It conceptualizes Burn-out as a syndrome ‘resul ng from chronic workplace stress that has not been successfully managed.

It is characterized by three dimensions:

Feelings of energy deple on or exhaus on.
Increased mental distance from one’s job, or feelings of nega vism or cynicism related to one’s job.
Reduced professional efficacy.

Burn-out refers specifically to phenomena in the occupa onal context and should not be applied to describe experiences in other areas of life. It excludes other condi ons such as adjustment disorders, disorders specifically associated with stress, anxiety disorders and mood disorders’ (ICD-11).

   

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How to recognize burnout?

It is important to recognize and deal with burnout. If le unno ced, there is a risk of it leading to fa gue, depression and ill effects in delivering clinical care. In the domains of clinical care, it can lead to increase in medical errors, reduced pa ent sa sfac on, early re rement or discon nua on of a medical career.

The typical symptoms of burnout among medical professionals are listed here:

       

Emo onal exhaus on: which can also manifest in physical fa gue
Cynicism and emo onal detachment from the course and job
Low sense of professional efficacy can lead to a feeling of being incompetent and worthless
Stress-related health problems such as acidity, headaches, body ache, sleeplessness etc.
Adverse impact on inter-personal rela onships
Feelings of aliena on which can lead to a sense of loneliness and that no one else understands what they are experiencing
Unhelpful coping mechanisms such as smoking, drinking excessively, engaging in substance abuse or gaming addic on
Poor concentra on and slowness in ac vi es especially connected with clinical work

Burnout among Psychiatry trainees : what is di erent about it?

It is important to recognize and deal with burnout. If le unno ced, there is a risk of it leading to fa gue, depression and ill effects in delivering clinical care. In the domains of clinical care, it can lead to increase in medical errors, reduced pa ent sa sfac on, early re rement or discon nua on of a medical career.

Psychiatry is one of the youngest branches of medicine. While the knowledge of the human mind, its workings and the understanding of the manifesta ons of psychological problems are an advantage to its prac oners, they are s ll just like other medical professionals, and are not immune to the effects of burnout.

Jovanovic1and colleagues in Europe studied burnout among psychiatry residents across 22 European countries. They found out that severe burnout was found in 726 (36.7%) trainees. The key risk factors for burnout in this study were long working hours, lack of supervision, not having regular me to rest and psychiatry not being the first career choice. In some worrying findings from Japan2and Portugal3, psychiatry residents were found to have higher rates of suicidal ideas. A systema c review4 of burnout among psychiatry residents, which largely included western studies showed an overall prevalence of burnout was 33.7%. The key associated factors were connected with

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training (juniors years of training, lower priority of psychiatry as career choice, lack of clinical supervision, discon nua on from training), work (high workload, long hours, insufficient rest), and learner factors (more stressors, greater anxiety, and depressive symptoms, low self-efficacy, decreased empathic capacity, poor coping, self-medica on, and use of mental health services).

Training in Psychiatry itself adds several very specific stressors, such as perceived s gma of the profession, consulta ons that tend to be longer especially ini al assessments, demanding therapeu c rela onships especially with difficult pa ents, personal threats from violent pa ents and losing pa ents through suicide.

Dealing with burnout as a psychiatry resident:

The foremost thing is to recognize ones’ threshold for stress and to know the general symptoms of burnout and symptoms specific to oneself. Trainees need to use supervision with seniors effec vely and learn from their experiences. They need to use formal arrangements such as the ‘Balint groups’ or the ‘Schwartz Rounds’ if they exist in the residency programs. If not, informal support groups of residents or the department colleagues can be designed to promote resilience and discuss about dealing with stress.

Residents also need to be aware soon in their training of boundaries in clinical prac ce and issues arising out of them such as dealing effec vely with transference and counter- transference. Personal coping mechanisms need to be recognised and implemented. These could include hobbies and interests that one already has or to learn new ones. Brief self-help strategies such as problem-solving therapy could be applied to issues that we go through.

Chan and colleagues refer to a 4S approach to helping psychiatry residents beat burnout. These are:

. 1  Selec on : There is evidence that residents choose psychiatry without knowing abouttheaspectsofthesubjectareathigherriskofburnout. Thismayincludethe need for new candidates to have worked in psychiatry rota ons prior to joining psychiatry residency programs.

. 2  Standard keeping of work and learning arrangements: This includes appropriate orienta on of new trainees, adequate and regular clinical supervision, adherence to duty hour rules and not working beyond s pulated working hours with adequate rest, a endances of requisite learning and supervision sessions, and tracking the compliance of training programs.

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. 3  Skills : Stress management techniques such as deep breathing, progressive muscle relaxa on, a reminder to pace and space out the metable of study, work, family, and leisure ac vi es to achieve work-life balance need to be reinforced. There is data to suggest that resident-led interven ons, including relaxa on and resilience training can be useful.

. 4  Support : from the people involved in the training program and at work is crucial to the trainee. This includes peers, senior residents, supervisors, and clinical faculty. A stronger support network would be helpful for all learners irrespec ve of seniority in training and prac ce.

Finally, it is useful to acknowledge that stress is ubiquitous and that no one is immune from it. The key is to learn to deal with it effec vely. I wish all the readers a burn-out-free residency and a long career as a psychiatrist.

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Appendix:

The Warwick–Edinburgh Mental Well-being Scale (WEMWBS – which has been reproduced below with the permission of the authors of the scale), lists the common items that indicate mental well-being. This is not a test to iden fy any psychiatric illness. You could use it to periodically monitor your stress levels.

Please circle the number that best describes your experience of each over the last 2 weeks

I’ve been feeling op mis c about the future 1 2

I’ve been feeling useful 1 2

I’ve been feeling relaxed 1 2

I’ve been feeling interested in other people 1 2

I’ve had energy to spare 1 2

I’ve been dealing with problems well 1 2

I’ve been thinking clearly 1 2

I’ve been feeling good about myself 1 2

I’ve been feeling close to other people 1 2

I’ve been feeling confident 1 2

I’ve been able to make up my own mind about things 1 2

I’ve been feeling loved 1 2

I’ve been interested in new things 1 2

II’ve been feeling cheerful 1 2

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

3 4 5

Warwick-Edinburgh Mental Well-being Scale (WEMWBS)
University of Edinburgh, 2006, all rights reserved.

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NHS Health Scotland, University of Warwick and

None of the me

Rarely
Some of the Time

O en
All of the Time

Dr. Ravichandra Karkal Associate Professor Department of Psychiatry Yenepoya University, Mangalore

Email id : minddocravi@gmail.com

 

LESSONS FROM THE ONLINE WORLD FOR A BUDDING PSYCHIATRIST

Internet and online tools have become an integral part of our lives. Our lifestyle is dictated by the internet to such a large extent that we all have a digital iden ty in addi on to our personal offline iden ty. These developments impact the educa on in psychiatry, presenta on of psychiatric disorders, pa ent educa on, assessment and treatment of psychiatric disorders. Thus, it’s impera ve that trainees in psychiatry have to be introduced to the ways in which new online technologies impact their training and future prac ce.

Digital and social media literacy : With the advent of the internet and online tools, change is inevitable for healthcare. We have to adapt to these technologies in training and prac ce of psychiatry to be on the cu ng-edge. There are many social media pla orms for doctors which deliver recent developments in the field of medicine, create a forum to discuss challenging cases seen in prac ce, give opportunity for con nuous medical educa on and help create networks with doctors all over India and the world. Social networking sites like Facebook and Twi er also create opportuni es to build your digital presence online.

Online technologies are also indispensable tools in crea ng awareness about mental health and figh ng s gma surrounding psychiatry. The social media’s influence on the public percep on of healthcare is immense, demonstrated by the rising cases of measles in the USA due to the online an -vaccina on campaign being run by ac vists. If healthcare professionals don’t jump ship and use social media to generate ra onal public percep on, pseudo-science and fake marke ng would damage public health to a grave extent.

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Professional behaviour in the digital world : As professionals, we have to take care of the digital footprint on various online pla orms. It is not uncommon to see doctors receiving flak for indiscriminate social media posts, not respec ng pa ent confiden ality. Our opinion and ac vi es online are open for everyone to see, and necessitates care from us to maintain a balance between our personal life and its impact on our profession.

Medical educa on in a digital world : There is no dearth of online resources for the present day psychiatry residents. In fact, some find it overwhelming and find it challenging to handle the informa on overload. Many universi es and experts in the field post ar cles, courses, videos, forum posts and blogs which have become an integral part of training for psychiatry residents. Quick reference can be done with sites/applica ons such as Medscape and UpToDate which compile the latest evidence based prac ces for clinical applica on.

Recent development of digital tests : Digital tests have been used to assess specific brain func ons such as memory, a en on, execu ve func ons for pa ents with demen a and schizophrenia. These tests have the same reliability as paper-and-pencil tests but have several advantages (such as the explora on of a wider range of ability, the minimiza on of floor and ceiling effects, the availability of a truly standardized format, and higher accuracy and sensi vity of recording test performance).

Collabora on for research : The internet has made collabora on with researchers easier than ever. Networking sites for researchers such as Academia.edu and Research Gate provides opportunity to showcase your research interests and connect with academicians worldwide.

Rise of the E-pa ents : There was a me when someone developing an health issue would seek the help of a trusted family doctor as a point of first contact. But a large sec on of our pa ents now knock the doors of Google doctor for asking health-related queries and find solu ons to their health related concerns. Many a mes it’s as if these “e-pa ents” have come to the real-life psychiatrist for a second opinion, as they would have self-diagnosed their condi on online. These e-pa ents look for health related informa on online and also search for doctors/clinics online. It’s thus impera ve that we build our online brand to reflect our qualifica ons and areas of exper se which increases our visibility. We also face a unique challenge as the internet is fairly unregulated and our pa ents run the risk of being conned by unqualified professionals who give online therapies and consulta ons. On the bright side, technology has helped in reducing s gma by crea ng awareness and has made professional care more accessible.

Telepsychiatry is an upcoming branch of psychiatry, with the trend moving towards online consulta ons. It is impera ve that all psychiatry postgraduates familiarize themselves with this, as digitaliza on of medicine, and psychiatry is an inevitable outcome of technologicalprogression.Onecouldarguethatthe‘human’orthe‘personaltouch’ gets

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lost while interac ng through digital screens, however high defini on the display might be, but due to the ubiquity of fast internet connec ons and me saving nature, telepsychiatry is well on its way to become the next big thing in this field, and many ins tu ons have already begun providing tele-follow-up services.

We also see a trend of using health and wellness applica ons by people in psychological distress. There are applica ons which use principles from Cogni ve Behavioural Therapy, Dialec cal Behavior Therapy, Acceptance and Commitment Therapy and Mindfulness to help clients in self-care. With the growth of Machine Learning and Ar ficial Intelligence in online tools, we see more applica ons in the mental health wellness domain. Although skep cs have cri cized that such applica ons will unnecessarily delay seeking help from a mental health professional, they can be helpful for those with minor psychological distress.

Behavioural disorders in the online genera on : The exponen al growth in the use of online tools for communica on and entertainment has seen a surge of behavioural disorders. Presenta on of every psychiatric disorder is being coloured by the online interac ons of the specific individual. Pathological and maladap ve behaviours surrounding the use of social media pla orms like Facebook, Twi er, Instagram, Whatsapp, Snapchat etc are commonplace in our clinical prac ce. Problema c video streaming and watching porn excessively are increasingly being recognized as dysfunc onal behaviours. Internet gaming disorder is now officially recognized by our nosological systems. Even though this has led to lot of cri cism that day-to-day behaviours are being medicalized, it is undoubtable that the future psychiatrist will deal with the repercussions of the explosive growth of the internet.

Finding Medical Information online- Useful online databases

SCOPUS It is free access and updated daily.

MEDLINE The most commonly used database with several search op ons

EBSCO Easy accessibility and mobile friendly

GOOGLE SCHOLAR

Academic materials are provided by users on a voluntary basis

OLDMEDLINE Useful for ar cles published prior to 1966

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Recommended Reading

Most of these virtual libraries have a tutorial guide and FAQs to introduce the reader to the ‘secrets’ of using the database. Look for them
Remember that there is no perfect, comprehensive database; all have advantages and disadvantages. Which database could be used for a literature search is a personal choice.

Today most psychiatric journals and their scien fic papers are now distributed in PDF format, and nearly all of these journals provide electronic tables of contents. (Psychiatric e-books are also freely downloadable). For researchers, sta s cal tools are also available online.

Take home messages:

A future psychiatrist should embrace online technologies in educa on, research, prac ce, evalua on of pa ent and their holis c management.
Make assessment of online ac vi es and behaviours a part of rou ne care of pa ents.

Stone J, Sharpe M. Internet resources for psychiatry and neuropsychiatry. J Neurol Neurosurg Psychiatry 2003; 74: 10–12.

  

1. 2.

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Importance of Peer Support

and Networking

Dr. Kiran Kumar K.
Associate Professor,
Vydehi Institute of Medical Sciences & Research Centre, Bangalore drkiran.psychiatry@gmail.com

“To keep a lamp burning we have to keep putting oil in it”

– Mother Teresa

Postgradua on is an important phase of learning in real-life situa on for the young students. For most of the undergraduate students gaining the coveted postgraduate seat of interest in a reputed medical college is the single most dream of their professional career. However, joining postgradua on for a fresh undergraduate is like opening the Pandora’s Box!

Residency training, in par cular, can cause a significant degree of burnout, leading to interference with individuals’ ability to establish rapport, sort through diagnos c dilemmas, and work though complex treatment decision making. In our country, the reasons of stress & burnout among young residents are unique, unlike in the west. Factors like poor doctor-pa ent ra o in India, limited specialty training programs, work-life imbalance, financial constraints, poor infrastructure, unstructured evalua on of performance, cost of medical educa on, unrealis c expecta ons from society and poor self-remedial measures for coping are few variables that are inimitable in Indian se ng.

Excelling in postgradua on with all the men oned barriers requires enormous peer support and networking skills. In fact, that’s what the most complex organ in the universe, our “Brain” has thought us, being able to have mul ple complex connec ons (Neuronal Plas city); is what makes it unique.

Research shows that peer learning provides important opportuni es to help new students cope in the first year of university and beyond as well as providing an important role model for student success.

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Peer learning can be defined as ‘the acquisi on of knowledge and skill through ac ve helping and suppor ng among status equals or matched companions’. Peer learning can be understood as a social process, in which peer interac ons are fundamental. Social interac on with peers is important for developing a sense of community, which is valuable for all students.

The world has become a ‘global village’ today and knowledge has become ubiquitous and easily available. But what’s important is how to find the accurate knowledge from the right person at the precise me. This requires extensive networking both in the ‘real’ and ‘virtual’ world.

It boils down to the ques on of how to improve peer support and how to network for be er outcomes during postgradua on. Here are few strategies that can be used for addressing this issue;

PEER GROUP : Peer learning can occur by forming a like-minded peer group. The ini a ve can be taken up either at the student level or officially at the level of organiza ons, which is followed at some ins tutes. The conceptual frame work can include peer learning , collabora ve learning, coopera ve learning, peer assisted learning, peer tutoring, peer facilita on, and peer mentoring. These studies share a central tenet that there is educa onal benefit in students taking responsibility for shared, self-directed learning from each other, working in groups independent of the teacher. That is, hierarchical status differences and barriers of power between fellow students are less than those between faculty members and students.

PEER NETWORKS : Peer network interven ons are designed to improve peer interac on and rela onships by suppor ng greater integra on into social environments. Although specific procedures vary, peer network interven ons share three core features: (a) establishing repeated interac on opportuni es during shared social ac vi es, (b) providing adult facilita on, and (c) equipping peers to be effec ve communica on partners.

1.
to their department, and to the University as a whole. Students usually feel there are “other people out there” and feelings of isola on is lessened. Measures like having a WhatsApp group or regular announcements in college newsle ers or other pla orms can facilitate improving connec ons.

2. Focus : Peer support & Network groups need to have a clear focus, be it academic or social. Appoin ng a senior student Moderator to incorporate precise focus and to prevent dilu on of the cause is very important.

I

II

Connec ons : Peer support group helps to connect students to each other, to staff,

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3. Leadership : Successful communi es and groups demonstrates strong leadership. Choosing a leader with virtues like open mindedness; the ability to draw on their own strengths and on the skills of others; friendliness; pa ence; good organisa on; and the ability to talk to staff members and to ask for help when necessary is essen al.

4. Open Membership : Successful groups are in general open to varied membership. Groups and subgroups can be formed on specific needs. It is essen al to always interact with members from other speciali es or sub-speciali es to gain important perspec ves and insight.

5. Departmental Support : It is very important and per nent to have departmental and administra ve support for implementa on of any peer support and network program. Having a supervisor, a mentor, financial assistance when required and having some perks in the form of coffee cards etc can all be obtained at the level of the department.

6. Safe Environment : Successful groups always require a safe, secure and comfortable environment for everybody. Mee ng in an alcohol-free, day- me situa on is proved to be the most popular se ng.

7. Face-To-Face Interac ons : Successful communi es and groups creates opportuni es for face-to-face interac on. Mee ng in neutral loca ons like the college club or one of the pre-designated class rooms is essen al and is proven to be be er than virtual interac ons.

8. Op mal Number : Leaders report needing a “cri cal mass” of at least six to eight students to enable them to enjoy good discussion and vitality. Having quite relaxed entry criteria usually enables groups to easily replace depar ng students with new ones. This can happen through word-of-mouth connec ons with exis ng members.

9. Networking : Establishing networking among peers and faculty across workplace and geographical boundaries are possible today because of the internet and social media. Crea ng appropriate pla orms (Facebook, WhatsApp, Telegram etc) is the need of the hour.

10. Milestones : Enjoying social, academic and personal milestones of each individual members can be sa sfying to the individual and empowering to others.

To conclude, given the myriad of stressors and individual preferences that a student encounters during postgradua on, a one-sized solu on is unlikely. Rather, strategies should systema cally engage trainees in addressing problems, use available resources, be grounded in best available data, be customized to the local environment and include a variety of approaches to improve peer support and networking.

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HOW TO BENEFIT FROM PROFESSIONAL CONFERENCES

Adarsh Tripathi*, Raj Rana **

*Associate Professor,** Senior Resident Department of Psychiatry,
King Georges’ Medical University, Lucknow

Email id : dradarshtripathi@gmail.com

Awareness about current standards and research in the medical field is of paramount importance for any medical prac oner. Even more so for a postgraduate resident, as they are at the incep on of their medical career. Incorpora ng the latest tools and prac ces including treatment regimens or therapies into their prac ce makes them be er clinicians and encourages evidence based management. More o en residents find it challenging to keep updated with the latest know-how, due to their work load.

Conferences in the field of medicine are gatherings of experts in the field to discuss a par cular topic of interest. These include updates on latest developments like diagnosis and treatment strategies, upcoming challenges, future prospects, providing updates and revisions on a selected area of clinical interest or just sharing of experiences of the clinicians. O en they comprise of delibera ons about a drug or a treatment strategy and explore and educate the a endees about its clinical role. Workshops are more interac ve and centre around the ac ve par cipa on of the a endees and o en focus on skill building and be er treatment strategies and the methodologies of these. These events are sponsored by medical and allied ins tu ons or at mes also by pharmaceu cal companies.

For resident doctors these events provide wonderful opportuni es for learning and expansion of their skill set. O en the topics discussed in these events are those that are per nent to clinical prac ce for example talks on the best available treatments or drugs for a par cular illness along with the regimens, doses and evidences. Other mes these discussions provide a refresher on the area of exper se, discuss clinical scenarios.

Workshops frequently include role-plays, enac ng of clinical scenarios, group discussions and thus allow for Socra c dialogues between the par cipants. They also encourage asking ques ons and clearing doubts relevant to the topic. These effec vely add a new

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dimension to the theore cal knowledge from a resident’s point of view and supplement their clinical experience. Students must par cipate ac vely to maximize learning and exploit chances of honing their skills. Students must keep in mind that group ac vi es are aimed at emula ng clinical scenarios. They must bring their clinical experience also into the discussions.

Workshops and conferences also provide residents with a wonderful pla orm to interact with stalwarts and eminent persons of the field. They may be senior doctors, visi ng experts or dedicated researchers who maybe a ending or officia ng the events. These experts are o en very willing to share their knowledge and experiences with the postgraduate students who should grasp such opportuni es gladly to further their own prowess and a ain mastery. At mes such interac ons may provide inspira on or guidance for a direc on of work a student may want to take.

Postgraduate students do not always get the opportunity to a end workshops and conferences owingtotheirbusyschedules.O enastheyproceedthroughtheirresidency they do get the chance to be a part of these events and are also presented with ample occasions for par cipa ng in various presenta ons and compe ons. So what must a postgraduate resident do in these events? They must approach them as academic getaways. Although they must keep in mind that only with a dynamic and energe c approach, these chances can be made to full use. Listening intently is essen al for this purpose and no ng down important points and ques ons.

At mes the topics being discussed may not be strong in grasp of the student. It helps if the students read the topic in brief beforehand to have some base knowledge. It also generates interest and also creates doubts and a quest for advanced facts and expert opinions. Students are encouraged to jot down doubts, ques ons, cri cal analyses etc. – that they may present later on in the event. They may approach the experts for these. Most events present with ques ons and answer sessions that may be exploited for this purpose.

Conferences also provide with wider opportuni es for students to showcase their talents in form of presenta ons and conferences. Students must approach these with posi vity and keen interest. Genuine effort put into these ac vi es enhances learning and also provides experience in the academic circuit which the students can build upon later.

Award papers are o en included in various conferences. These ac vi es are aimed at improving focus on good quality research, learning strategies to organize and present research work in a me bound manner, ability to cri cally analyze own and other’s research work and ask per nent ques ons, improve their quality based on discussions and feedback from other par cipants. Presenta on of various research papers by students provide an opportunity to witness research trends in discipline, areas of poten al research and help in clarifying many doubts related to research during thesis work.

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Compe ve events like quiz, promote focused learning, improving objec vity in one’s knowledge, improving reac on me and promo ng ability to par cipate in friendly yet s mula ng scien fic knowledge events. Both par cipa on and witnessing these events provide interes ng learning situa ons.

Many conferences provide opportuni es to young colleagues in the form of fellowship, economic advantages, grants for traveling and accommoda on as well as focused sessions for young trainees and professionals. Such opportuni es should be sought for and u lized as much as possible. It provides wide exposure and learning opportuni es in early career.

Various training and teaching ins tu ons have different strengths and weaknesses in different sub-special es of psychiatry. It can therefore be an opportunity for trainees to be exposed to seminars, lectures and workshops of different sub-special es like child and adolescent psychiatry, addic on psychiatry, geriatric psychiatry, consulta on-liaison psychiatry, forensic psychiatry, different types of psychotherapies, neuroimaging, electroconvulsive therapy (ECT) and brain modula on treatments, psychopharmacology, rehabilita on psychiatry, research methodology and sta s cs, ethical principles of research and clinical prac ce.

Table 1:

Conferences Lectures/symposium

Gathering of experts in the field to discuss a par cular topic of interest.

O en focused on delivering focused informa on.

May provide opportuni es for residents to present their work.

Workshops More interac ve and centred around the ac ve par cipa on of the a endees.

O en focus on skill building and prac cal ps.

Award papers Unique opportunity to present research work in front of colleagues from different ins tu ons and or countries.

Discussion, ques ons, cri cal analysis and feedback provide learning prospects.

Quiz Objec ve knowledge.

Improve reac on me, learning in intense yet enjoyable environment.

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Take home message

Postgraduates should prepare for conferences by reading beforehand, par cipa ng energe cally, asking ques ons, listening ac vely and taking quick notes for taking full advantage.
Use the opportunity to network and interact with other faculty, delegates and even experts in your field of interests. This could also foster career advancement at a later stage.

Remember to share your learning experiences with your peers when you return

Recommended Reading

Singh MK. Preparing and presen ng effec ve abstracts and posters in psychiatry. Acad Psychiatry. 2014;38(6):709–715.

Thomas C Erren, Philip E Bourne. Ten Simple Rules for a Good Poster Presenta on. PLoS Comput Biol. 2007 May; 3(5): e102

Bourne PE. Ten simple rules for making good oral presenta ons. PLoS Comput Biol. 2007 Apr 27;3(4):e77.

      

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Teaching: A means to become a better psychiatrist

Rishikesh V. Behere

Wellcome DBT India Alliance Intermediate Fellow Associate Consultant Psychiatrist KEM Hospital Research Center, Pune

Email id : rvbehere@gmail.com

STUDENT BE MY TEACHER!

 

A postgraduate residency in psychiatry is an exci ng phase in the life of a medical student wan ng to train in psychiatry. It is an opportunity to tread into the world of understanding psychopathology, abnormal psychology and skills of interviewing techniques and empathy. These are skills that are ‘learnt by doing’ by way of role plays and by observa on.

A resident has to don many hats. She/he is a doctor, a trainee psychiatrist, a student and a budding researcher. In addi on to this, she/he may also be called upon many a mes to don the hat of a teacher to take classes for undergraduate students and paramedical courses. This may some mes be seen as an addi onal responsibility on the already overburdened shoulders of a postgraduate resident. But let me argue that this is not an addi onal responsibility but an integral part of training to be a be er psychiatrist.

What are the advantages?

An old Chinese proverb says “I hear and I forget, I see and I remember, I do and I understand”. Let me add to this a phrase “I teach and I master!”. The process of teaching is not just a passive process of impar ng knowledge, but to be able to convey informa on you need to first master it yourself. This act can induce a new level of understanding of the subject and also see the transforma on into a new level of confidence when you discover a new-found mastery over the knowledge or skill. As Aristotle has said that “teaching is the highest form of understanding.”

Being on the other side of the table helps to see things from the teachers’ perspec ve. This actually helps you to understand what are the expecta ons of an examiner in an exam and what mistakes to avoid.

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What are the benefits?

This concept of student led teaching is also called as ‘peer teaching’ and has been widely experimented in various teaching ins tutes across the world. Studies have also been conducted to analyze the efficacy of these teaching methods. It has been consistently found that peer teachers have larger gains in learning the content that they have taught and the knowledge is retained for longer periods of me. The mechanisms by which peer teachers benefit with improved learning are – 1) Be er mo va on to learn the content 2) Deeper processing of learned informa on (conceptual learning) 3) Be er self-monitoring of their own comprehension of learned knowledge. Added advantages of ‘peer teaching’ include be er communica on and leadership skills. It has been found that students ini ally may be apprehensive to take up this role of teaching due to their anxie es and lack of confidence in their own teaching abili es. However, it has also been demonstrated that learning outcomes in the students by ‘peer teaching’ methods are equivalent to that of conven onal faculty led teaching.

Advantages of student led teaching:

Be er understanding and learning
Developing be er leadership and communica on skills
Gaining teaching experience which may be mandated by regulatory authori es for future appointments as faculty

Some recommendations:

In the current scenario, this happens informally. A final year postgraduate resident who monitors work of a first year junior resident, may be asked to fill in for class (theory or clinics) for an absent faculty member. This could be formalized by incorpora on into a residency program, ac vi es such as:

Demonstra on of psychopathology and interview techniques for first year residents by senior residents.
Final year PG’s could chair academic programs such as case conference and seminars presented by junior residents.

Formal lectures for MBBS graduates and paramedical professionals.
Involvement of postgraduate residents in mental health awareness programs for other medical professionals and general public on occasions such as mental health week.

Teaching is an important ac vity for a resident as part of their training especially considering that most of them are going to be associated with medical ins tu ons and teaching hospitals in the future. Hence residents need not see it as an addi onal responsibility but as a means to become a be er psychiatrist!

      

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Some teaching tips for postgraduates to use (when they teach MBBS students or interns or Junior PGs)

Think of the teachers you have had who have been influen al in your residency or even as a MBBS student. Reflect on the things they did well and techniques you could emulate

Set specific objec ves. Begin a teaching session by telling the students what you want them to learn. It is easier for students to learn be er when they know what they are expected to learn

Ac ve learning is be er than passive learning. Ask students a ques on, ask them to show you a few steps in a procedure, or ask them to teach you or another student. Try to get one student to talk every 5 minutes

End a teaching session by asking them to summarize the concept you have just taught them and to demonstrate/perform the skill discussed.

Give students feedback. Tell them what they did well, what could be improved on and how to implement these improvements next me.

Try to ensure that every contact you have with a student includes a teaching moment be it is even for only a few minutes.

     

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Dr. Bharathi G,

Assistant Professor,
Department of Psychiatry,
Hassan Institute of Medical Sciences, Hassan

Email id : drbharathig74@gmail.com

If there is anything a professional should know, it is Ethics. A postgraduate who learns and applies ethics in everyday life upholds a supreme order and is revered by all. Ethics (Greek word ‘ethos’ meaning “custom, habit, character or disposi on”) refers to the principles dicta ng rights and wrongs with regard to the conduct of human behaviour in the society. Some ethics differ from place to place and from me to me, while on the other hand there are some which are Universal and persists in all the regions and at all mes.

Ethics in the medical profession is guided by Hippocra c Oath (460 BC) and The Interna onal Code of Medical Ethics (1949). Medical code of ethics in India follows Indian MedicalCouncil(Professionalconduct,E que eandEthics)Regula ons,2002 amended 2016. Physician on entering into the profession signs a declara on which includes the code of conduct. In general, a physician shall uphold the dignity and honor of his profession, with a prime object of rendering service to humanity; reward or financial gain being a subordinate considera on. The physician shall observe the laws of the country in regula ng the prac ce of medicine and shall also not assist others to evade such laws.

Ethics pertaining to postgraduates (Pgs): PGs face many ethical issues during their training. These could be pa ents/caregivers related, interac on with teachers/seniors/ colleagues, research related and many other situa ons.

Patients/caregivers related:

The Pa ent must not be neglected. Skills and knowledge should be used appropriately in trea ng the pa ent. Prognosis of the pa ent’s condi on should be neither exaggerated nor minimized. Pa ent/rela ves/responsible friends should be given knowledge of the pa ent’s condi on so as to serve the best interests of the pa ent/family. As far as possible, prescribe drugs with generic names and legibly. Prescrip on and use of drugs should be ra onal. Physician should respond to treatment request during emergencies.

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Importance of Ethics

1 therulesbasedontheSec on20AreadwithSec on33(m)oftheIndianMedicalCouncilAct,1956
2 Doctors with qualifica on of MBBS or MBBS with postgraduate degree/ diploma or with equivalent qualifica on in any medical discipline – defined in Chapter I Code of Medical Ethics
3 i) in a court of law under orders of the Presiding Judge; ii) in circumstances where there is a serious and iden fied risk to a specific person and /or community; and iii) no fiable diseases. In case of communicable / no fiable diseases, concerned public health authori es

Another important issue during PG training is maintaining confiden ality. Confidences concerning individual/domes c life entrusted by pa ents to a physician and defects in the disposi on/character of pa ents observed during medical a endance should never be revealed unless their revela on is required by the laws of the State . Here is an important ethical issue for PGs, wherein they are expected to reveal the details to their senior/consultants, which some pa ents may object. This possibly can be resolved by explaining to the pa ent the importance of discussing their problems with the teachers and other colleagues and their role in treatment. The same also applies during Case presenta ons where-in prior informa on to the pa ent and an informed consent from the pa ent would be desirable to avoid ethical issues. No informa on should be revealed to those not concerned/not involved in treatment of the pa ent without the pa ents’ consent. It is expected that the Postgraduate shall seek a senior from the same or a different profession whenever there is a dilemma. Learning evolves over period of me and ethics are simple to apply as it greatly enhances righteousness and profession happiness.

Keep in mind the confiden ality issue in daily prac ce, especially in certain high-risk scenarios like wai ng rooms, telephone conversa ons and emails. Avoid casual discussion about pa ents with family or friends even if they are colleagues. Also remember to use cau on in recording medical informa on. Keep medical records and all wri en informa on concerning pa ents in a safe place.

Psychiatry training consists of long and frequent contact with pa ents which can increase the risk for boundary viola ons. Boundary viola ons are aberra ons from clinical prac ce that could be harmful and exploit the pa ent’s emo onal, physical or financial needs. This includes the psychiatrist or trainee engaging in a business or social rela onship outside of the therapeu c context. It is therefore necessary to set boundaries beforehand and prevent such situa ons altogether, which can be achieved through open and clear communica on between the pa ent and the psychiatric trainee.

Research related:

Research is mandatory part of the PG training and this is a period during which many young doctors par cipate in research for the first me in their lives. Research Ethics is guided by interna onal and na onal guidelines. The Nuremberg Code (1947) highlighted the essen ality of voluntary consent. In 1964, Declara on of Helsinki was formulated (amended 2013). Belmont report (1979) gave three basic ethical principles: respect persons, beneficence and jus ce. The revised Indian Council of Medical Research ethical .

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guidelines (Na onal Ethical Guidelines for Biomedical and Health Research involving

human par cipants, 2017) have adopted from Interna onal guidelines keeping in mind

4 the diverse Indian socio-cultural milieu .

Dealing with teachers and other colleagues:

Respec ng teacher (needs no emphasis/discussion) is a code of conduct from me immemorial. The code of ethics tells us the role of a doctor working as a subs tute or as a cross-consultant. It points out that no insincerity, rivalry or envy should be indulged in such situa ons.

4 UNESCOs Universal Declara on on Bioethics & Human Rights (2005) and other Interna onal instruments on Human Rights

All due respect should be observed towards the physician-in-charge of the case and no statement/remark be made, which would impair the confidence reposed in him. For this purpose no discussion should be carried on in the presence of the pa ent / his representa ves. However, one should expose, without fear/favour, incompetent/corrupt, dishonest/unethical conduct on the part of members of the profession to appropriate authori es.

Dealing with Medical errors

Medical errors o en lead to severe punishment of the concerned doctor, which could range from suspension of right to prac ce medicine, to revoca on of licence, to even arrest. The inevitable consequence of this is that doctors are trained to conceal errors, as it may lead to the loss of livelihood. These are a few ps to prevent errors, and therefore nega ve outcomes.

Timely, authen c and sensi ve communica on with pa ents, nursing staff, caregivers, and other peers and professionals will in most cases prevent any avoidable complaints and li ga ons.
Good record keeping and documenta on-Wri ng down ra onale for treatment decisions

Encourage nursing staff to have appropriate records of all clinical events
In case of any nega ve events, talk to the pa ent, family and caregivers. Apologize for any distress. Be honest about things that went wrong (This does not imply that you admit liability for treatment decisions. It is vital for the resident to discuss with the senior consultant at all mes before having such conversa ons with pa ents)

Dealing with pharmaceutical companies:

Another important field where ethical prac ce is at risk is interac ons with pharmaceu cal companies. Code of conduct for doctors & professional associa ons of doctors in their rela onship with pharmaceu cal and allied health sector industry

       

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prohibits them from accep ng any gi s, travel facility, hospitality or cash or monitory grant,fromanyofpharmaceu calcompanyorthehealthcareindustry. Apartfromthe sanc ons imposed as men oned in the regula ons for such acts, at a personal level, one should introspect about the obliga ons the Physician will have with companies, on such gains from them. This situa on is detrimental to ones’ ethical prac ce with respect to prescrip ons, having its adverse influence in trea ng pa ents. An Unholy nexus with pharma companies can jeopardise the joy of becoming a doctor.

The other aspect is research project funded by the pharmaceu cal companies, a medical prac oner may carry out, par cipate in or work in such projects a er ensuring that the par cular project has due permission from the competent authori es. The prac oner also has to ensure that the research project gets clearance from an ins tu onal ethics body.

Take home message

Golden Rule: Do unto others as you would have them do unto you.
It is important for a PG to build knowledge about fundamental medical ethical principles, as many may breach ethical codes simply because they are unaware of them.

  

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Ethical Knowledge and practice checklist

Knowledge:

yes/no/not sure

1. Know about Hippocrates Oath

2. Know about Interna onal code of Medical ethics

3. Know about Indian Medical Council (Professional conduct, E que e and
Ethics) Regula ons, 2002 & recent amendments

4. Know about state laws related to your speciality

5. Know about ins tu onal ethical commi ee

6. Know about Nuremberg Code

7. Know about Declara on of Helsinki

Know about Universal Declara on on Bioethics & Human Rights
9. Know about Na onal Ethical Guidelines for Biomedical and Health Research

8.
involving human par cipants, 2017

Should I improve on my knowledge on any of the above topic (yes/no)

If yes, specify and read about it

Prac ce:

yes/no/not always

1. Respond to request during emergencies

2. Talk with respect to pa ents/rela ves

3. Give correct informa on to the pa ent/rela ve about the clinical condi on

4. Give correct informa on about the short/long term prognosis to the pa ent
/rela ves

5. Prescribe drugs with generic names

6. Prescribe drugs legibly

7. Take informed consent (wri en) in clinical prac ce

8. Do not discuss about pa ent with those not concerned

9. Take informed consent (wri en) for research related subjects

10. Give correct informa on to the pa ent about the research project

11. Talk with respect about your teachers

12. Talk with respect about other Doctors in front of the pa ent/rela ves

13. Accept any gi s/travel facili es/hospitality/cash or monetary grant from
pharmaceu cal company

14. Involved in pharmaceu cal company funded research project (yes/no)
If yes,
Is the project approved by competent authori es
Has clearance been obtained from Ins tu onal Ethical Commi ee

Should I introspect to change some of the above ethical prac ce issues (yes/no)

If yes, specify and go ahead for the change

 

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Beyond Textbooks: Literature as an effective tool for students of psychiatry

Dr Ashlesha Bagadia, Perinatal Psychiatrist & Psychotherapist
The Green Oak Initiative, Annaswamy Mudaliar General Hospital

Email id : ashlesha.bagadia@gmail.com

“But will I always love her? Does my love for her reside in my head or my heart? The scien st in her believed that emo on resulted from complex limbic brain circuitry that was for her, at this very moment, trapped in the trenches of a ba le in which there would be no survivors. The mother in her believed that the love she had for her daughter was safe from the mayhem in her mind, because it lived in her heart.” Lisa Genova- S ll Alice.

The above passage demonstrates the inner turmoil of a Linguis c Professor as she comes to terms with her diagnosis of Demen a. The difficul es experienced by pa ents faced with such a diagnosis can o en be explained be er through literature. While it is important to understand mental illness from a clinical perspec ve and be well versed in the symptoms, ae ology, treatment, prognosis, etc, students can get a be er grasp of the complexi es of the same from literary fic on. Mental illness is a culmina on of biological, psychological and social factors, dynamically shi ing and changing over me as pa ents move through different life stages and interact with people around them. Books that tell a story or narra ve of a persons struggle with mental illness can e in all the factors in a way that can engage a reader and enhance learning.

Another aspect that is explored be er through literature, is co-morbidity and the interplay of factors which can lead to mul ple mental health issues. In “Perks of being a Wallflower” Stephen Chbosky highlights issues of substance misuse, PTSD and Depression and their interconnected rela onship.

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Books can also help postgraduate residents understand narra ves of those unfamiliar to them, such as from different age groups or from different cultural backgrounds. “Persopolis” by Marjane Satrapi is an autobiographical graphic novel that shows issues faced by women in Iran and the impact of shi ing poli cal systems on the public. Although this is a book for adults, there are many picture books for children that explore difficult themes through simple narra ves. “Ruby’s Worry” by Tom Percival tells a story of a li le girl whose worry follows her around, gradually increasing un l she talks about it with someone. Such picture books can also be used in clinical prac ce to help young children be er understand mental illness.

Lighter narra ves can use humour to break the monotony of reading grim details from standard textbooks and fill the students with hope. “Finding Audrey” by Sophie Kinsella is a funny and heartwarming story of a girl struggling with social anxiety and bullying. “A Man Called Ove” by Fredrik Beckman is a poignant, humorous account of a lonely widower’s failed a empts at suicide, while his new neighbours make him realise he’s s ll valuable to the community.

Apart from fic on, non-fic on books, autobiographies and case summaries also have much to offer students of mental health. Irvin Yalom’s “Love’s Execu oner and Other Tales of Psychotherapy” is a great collec on of cases that follows pa ents through their progress in therapy and resolu on of symptoms. Yalom’s humility and ability to understand and accept his own shortcomings, sets a good example for future prac oners of therapy. Books that increase the reflec ve capacity of students can also help them overcome their own difficul es and become be er clinicians in the future.

One of the most important clinical tool for any doctor is empathy and ability to engage with the pa ent. While this is true for most special es, it is especially applicable to psychiatrists. There is good evidence to demonstrate that reading mental health depicted in literature increases empathy and helps the reader to understand the human behind the illness. (Djikic et al, 2013).

“But it seemed as if all psychiatric medicine was aimed only at the symptoms. Mute the paranoia. Calm the rage. Raise the endorphins. Underneath, the mysteries con nued, unchanged. Underneath, somewhere in the chemistry of her brain, there was something that could not be reached.” Jerry Pinto- Em & the Big Hoom.

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Recommended Reading

Djikic, M., Oatley, K., & Moldoveanu, M.C. (2013). Reading other minds: effects of literature on empathy. Scien fic Study of Literature, 3 (1), 28-47

A few recommended books

What Pa ents Say, What Doctors Hear by Danielle Ofri The Man Who Mistook His Wife for a Hat by Oliver Sacks How Doctors Think by Jerome Groopman
The Center Cannot Hold by Ellyn Saks

An Unquiet Mind by Kay Redfield Jamison
The Curious Incident of the Dog in the Nigh me by Mark Haddon It’s Kind of a Funny Story By Ned Vizzini
The course of love – Alain De Bo on
Mad, bad and sad – Lisa Appignanesi
Musicophilia – Oliver Sacks
Chicken with plums – Marjane Satrapi
Coun ng by 7’s : Holly Goldberg Sloan
Eleanor oliphant is completely fine by Gail Honeyman
Quiet by Susan Cain

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DNB Training

DNB TRAINING AND EXAMINATIONS

Dr. Priya Sreedaran,

Associate Professor, Department of Psychiatry,
St. John’s Medical College Hospital,
St. John’s National Academy of Health Sciences, Bangalore

Email id- drpriyasreedaran@gmail.com

Unlike MD psychiatry exams, DNB examina ons are perceived to be more difficult to pass due to absence of internal examiners. However, DNB training has several strengths. DNB psychiatry training ins tutes o en have very good pa ent caseloads with senior consultants who ac vely treat pa ents and thus have immense clinical experience. Hence DNB students have the opportunity to observe these consultants at work and see ‘real world’ clinical prac ce of psychiatry.

DNB candidates should work at making sure that they get the right amount of academic training and rigor. The Na onal Board of examina ons (NBE) as well as the Medical council of India (MCI) has prescribed a clear academic schedule comprising of a minimum of 12 case conferences, journal clubs and seminars for candidates during their period of residency. Candidates should aspire to meet this target and take the cri cal feedback about these presenta ons seriously.

DNB candidates should a end all research methodology workshops arranged by NBE and aim to establish good contacts with their fellow par cipants and faculty. These networks will help them with respect to any doubts about their disserta on as DNB training can -at mes- be a lonely affair for the resident.

A key concern for DNB primary and secondary candidates is training in psychotherapy. Candidates should check with their ins tu ons about the nature of training they can expect.

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Studying for examinations

Since there is a shortage of clinical psychologists across the country, it is possible that training ins tutes might not be able to provide adequate clinical psychology exposure. In such cases, candidates should regularly check websites of ins tu ons like NIMHANS where there are periodic workshops on psychotherapies. The internet is a very useful resource for simulated demonstra ons of psychotherapies. Candidates can check out http://www.beckins tute.org and http://www.behavioraltech.org for online training courses on Cogni ve Behavior and Dialec cal Behavior therapy. These online courses are very expensive. Candidates should read the theory pertaining to these psychotherapies simultaneously.

Candidates should a end their external pos ngs in departments like neurology diligently and strive to present cases and improve their pa ent examina on and diagnos c skills. Candidates should painstakingly maintain their logbook which will serve as a huge help in the future for them.

Periodic reading is necessary for candidates to improve their clinical skills. Candidates should scan all the standard textbooks of psychiatry over a period of 1-2 months a er joining the course. All psychiatry textbooks are excellent. Candidates should finally select any one or two textbooks that they find easy to read rather than trying to opt for a very difficult book that has been recommended by others. This will help candidates develop a regular reading habit.

In the first year, candidates should focus on developing skills in taking a psychiatric history, performing a mental status examina on and arriving at psychiatric differen al diagnoses. Candidates should read according to the diagnoses of the pa ents that they are currently managing. For e.g. if you are seeing a case of schizophrenia, it would be good to read about the phenomenology, course, outcome and management of schizophrenia. Candidates should brush up on psychotropic drugs on a constant basis. Candidates should aim to complete a thorough reading of phenomenology, classifica on and psychopharmacology in their first year of residency.

From their second year of residency, candidates should read the relevant theory chapters during their pos ngs in various psychiatry subspecial es like forensics, community and child psychiatry and avoid postponing reading of theory of these ll last minute. In the last six months of their residency, in addi on to revision of the aforemen oned, candidates should periodically check Indian Journal of Psychiatry, Indian Journal of Psychological Medicine and other Indian journals for prac ce guidelines as well as review ar cles.

Candidates should try to a end all zonal and na onal con nuing medical educa on programs in psychiatry.

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These are excellent avenues for training vis-à-vis all aspects of training for examina ons. Candidates could also check out the NIMHANS virtual knowledge network website for various case discussions. As per Medical council of India requirements, candidates are expected to complete one oral and one poster presenta on along with a publica on. Around 6 months before theory examina ons, candidates should invest 2-3 days in making a ques on bank. Candidates should collect ques ons over the last 5 years from various universi es and list these under a broad heading. This will make the candidate aware of the various ways in which theory ques ons are derived from a par cular topic. For e.g. over the years, ques ons of circadian rhythms have been listed as ‘circadian rhythms’, ‘endogenous zeitgebers’ ‘diurnal varia ons in human body’ etc. Candidates should aim to revise at least 4-5 such ques ons daily. This type of studying is useful in breaking monotony during reading for theory. For e.g. if you are red of reading about learning theories, you can always switch to a clinical topic like course of bipolar disorder.

Candidates should prac ce wri ng answer papers in the last 2-3 months as this will improve their speed. Most candidates usually struggle to complete the first few model papers and their speed improves over me. In DNB exams, there is usually a 3-4 month gap between theory and prac cal exams. Hence it is definitely worth the while to try to take leave before the theory exams. Once theory exams are over, candidates should try to rejoin clinical work as soon as possible. It is quite difficult to clear prac cal exams if the candidate is out of touch.

Candidates should try to work up and present as many cases as possible during their residency. Candidates should aim to work up their cases thoroughly avoiding any short- cuts like skipping fundus examina on etc. Bad examina on prac ces have a knack of ge ngexposedduringthefinalprac calexamina on. Acandidatewhodoesnotcheck deep tendon reflexes during a rou ne case work up is very likely to make the same mistake in the final examina on. Candidates should persist with reading of journals as poten al examiners’ areas of interest and exper se can be made out through their publica ons.

During DNB prac cal examina ons, candidates should dress formally and a end to their hygiene and grooming. Candidates should not get anxious if they are unable to speak the language of their pa ents. Examiners are very cognizant of this and examina on centers usually make excellent arrangements for interpreters. It is noteworthy that primary DNB candidates have obtained the psychiatry gold medal on mul ple occasions.

To conclude, systema c planning, regular reading and sincere efforts during clinical residency have the poten al to make DNB training for most candidates a very rewarding experience.

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Key message:

Read as per cases seen

Read as per academic schedule

Consolidate on years 1 &2

Read from CME topics Read journals
Prac ce theory papers

Read as per cases seen

Read as per external pos ng

Periodic reading of forensic & community

Consolidate on year 1

Read as per academic schedule

Read as per cases seen Diagnos c guidelines Psychopharmacology Phenomenology

Basic psychology

Read as per academic schedule

1. A commi ed and diligent psychiatry DNB student can definitely pass the DNB examina ons.

2.
perseverance.

The key to a successful comple on of DNB course is smart planning and

  

Year 2

Perform clinical work diligently

Year 3

Perform clinical work diligently

Year 1

Perform clinical work diligently

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PLANNING FOR SUB-SPECIALISATION IN PSYCHIATRY AFTER RESIDENCY

Dr. Vijaykumar Harbishettar Consultant Psychiatrist & Associate Director for Dementia Care Nightingales Medical Trust, Bangalore

Email : drvijaysh@gmail.com

A er comple ng Postgradua on in Psychiatry, for many doctors, it is not over yet, they get stuck in the next set of cross-roads. Generally, many doctors wish to complete MD or DNB in Psychiatry. A er MD, whether to take up Senior Residency or do a super-specialisa on as recently there have been upsurge of DM seats in Psychiatry in India is a big challenge.

Child Psychiatry : Ini ally it all began as Child Guidance clinics in Mumbai and later on different ins tutes in India including at NIMHANS from 1959. NIMHANS started Post- Doctoral Fellow (PDF) in 2008 and DM course in Child Psychiatry in 2012. PGIMER in Chandigarh also started this course in 2014.A two year PDF course is also available in CMC Vellore. MoredoctorsopttoapplytogetintoDMcourseinchildpsychiatryinIndiathan any other super-specialty. Curriculum is focussed on training doctors to make them super- specialists in Child and Adolescent Psychiatry. The Departments have evolved into Mul – disciplinary Team and are offering holis c assessment and management of childhood psychiatric disorders.

Addic on Medicine : DM courses in Addic on Medicine is offered in NIMHANS, AIIMS – New Delhi and PGIMER – Chandigarh. Curriculum is developed around the aspects of addic ons and holis c assessment and management is provided for the pa ents with substance use disorders.

Geriatric Psychiatry : A separate department of Geriatric Psychiatry was first developed in KGMC – Lucknow, which helped them to start DM course. NIMHANS Geriatric Psychiatry unit followed and started their first DM course in Geriatric Psychiatry from July 2017.

Other Super-special es : NIMHANS has approved Forensic Psychiatry DM course and the course is yet to start. Apart from all the above men oned super-special es, other super- special es such as Community Psychiatry, Emergency Psychiatry, Perinatal Psychiatry, Non Invasive Brain S mula on, Schizophrenia, Neuro-psychiatry have started Post- Doctoral Fellow Course each for a period of one year.

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HowtheyChoose: Firstofallonehastobeclearwiththereasonforwan ngtodoDM course. Some of the doctors say that they feel secure, having a Doctor of Medicine Degree from an Ins tute which has structured formal training and feel they may get recogni on from that. Some doctors having done their disserta on in a par cular area for example, in Addic ons or Child or Geriatric Psychiatry, may become fascinated by that par cular super-specialty that helps them to choose. The choice may also be determined by the perceived demand in the area of super-specialisa on. Interest in Demen a, will become a good reason to take up Geriatric Psychiatry. Another reason is to try to secure a faculty posi on in a par cular ins tute in that specialty which forces them to decide to write DM entrance examina on. This is due to the fear that if they apply to Faculty posi on in any of the Departments in Psychiatry, doctors having DM degrees may get preference, which may be true in the coming days.

How to go about : First and foremost, set goals for self. Find out if a par cular super- specialty is something you are passionate about. Next thing is to know the curriculum for the course you are thinking to go in and know what training would help them. One has to decide before applying, because once you take up a course, you do not want to feel that it’s not for you. You may need to plan based on experiences during speciality and periphery pos ngs during PG, and plan prepara on for the DM and PDF entrance exams during PG itself, which would give you an extra edge in these exams. Also, one must know that while prac cing as post MD you can s ll choose to have special interest in a par cular area and develop yourself clinically.

Academics : If the post MD doctor has a passion to be a full me researcher in a par cular area in Psychiatry, PhD course may be an op on. This may be pursued while working as well as while doing Senior Residency. DM course can also help in se ling in one of the super- specialty and pursue a research career in that area that one is interested in.

Personal/Family life : By the me, one completes MD, the person may be nearing marital life. One has to bear in mind, preferences may change. For some, career may s ll be a priority, and they may decide to pursue a par cular course. But for others, they become flexible. The choice of pre-decided place of se ling, whether abroad or India or a par cular place in India, may also be a major factor in deciding a par cular super- speciality. It is important that you may have dialogue with your kin and if there is a need, buy me and not to rush.

Talking to Mentors/Teachers : Some mes, you know a par cular supervisor so well, that you may become influenced and so discussing with the mentors, thesis guides or other family friends about your choices may help. The idea is to get as much informa on as possible as it is s ll going to be your best guess of the future, how the future is going to be once you have done a par cular super-specialty. Therefore, collect informa on, take me and choose wisely. The decision taken based on the informa on you have gathered from various sources, given due considera on to your personal life and your strengths and passion, would be best possible thing you can do.

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Ques ons which may help you choose a sub-speciality: (we suggest you take this exercise a er a reasonable amount of me spent working in psychiatry, so that there is exposure to various branches)

Firstly, do I want to con nue further with studies or start working a er

1.
comple on of MD?

2. If yes, how long do I want to study for? Do I want to do a fellowship or a full three-year DM course?

3. The subjects I was originally interested in during my undergraduate course were________________________________________________________

4. Would I want to work in a primary health care se ng and focus on community mental health?

5. Would I want to work on cases with associated legal issues?

6. Am I interested in working in an emergency medical se ng?

7. Would I be comfortable working in areas strongly related to core physics and
neurobiology?
Do I want to work exclusively with children and adolescents?

9. Do I envision my career working as a psychiatrist at a school or college, working
on students’ mental health?

10. Do I want to work exclusively with the elderly and geriatric mental health?

11. Am I interested in women’s mental health? Would I want to work with
obstetricians and paediatricians and focus on perinatal psychiatry?

12. What is my strength? Core medical management or psychological interven on?

Once you have a fair idea of what to choose, answer these:

1. Do I know enough about this area of study?

2. What would the requirements be, in terms of academic, research and clinical
responsibili es expected from me?

3. Which ins tu on offers the best course in this area?

4. What are my future career prospects a er specialisa on?

5. Is this a good fit for me? Do I have the necessary skillset for this par cular
branch?

8.

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PREPARING FOR A CAREER IN PSYCHIATRY AFTER POSTGRADUATION

Prof. Sanju George

Professor of psychiatry and psychology Rajagiri School of behavioural sciences and research Rajagiri College of Social Sciences,
Kochi, Kerala.

Email id- sanjugeorge531@gmail.com

Confucius is credited with the saying – ‘Choose a job you love and you will never have to work a day in your life.’ This is very true when it comes to preparing for a career in psychiatry a er postgradua on. The word ‘choose’ in the saying above is par cularly relevant – in most of medicine, and even more so in psychiatry, one’s career is all about making choices – hopefully the right one at the right me. But then, some would argue that luck plays a key role in shaping one’s career, but I believe that you can ‘create’ your own luck by working very hard. Career choices a psychiatrist (post-MD) makes should primarily be determined by what he/she is capable of or is good at. No one knows your strengths and weaknesses as well as you do – so choose smartly. If one spends me doing what one is good at, what one loves, and with all his/her heart, then work truly becomes and remains enjoyable.

Before we explore the various career op ons open to psychiatrists, a crucial ques on that needs to be asked is ‘WHEN does one start this process?’ And the answer is – ‘AS SOON AS- ———–’. As soon as you se le into your postgraduate training, start planning your future. Because it o en takes me to translate plans into ac on, and if you start early it gives you me to switch op ons, if things don’t work out as planned.

Although somewhat arbitrary, a key dis nc on in terms of a career in psychiatry, is clinical vs.academic. It has to be said that the various types of post-MD career op ons are not mutually exclusive. In prac ce, there is o en an overlap; but if there is too much of an overlap, where one ends up doing a bit of everything and not a lot of any one thing, there creeps in the danger of one ending up becoming a ‘jack of all and master of none.’

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Clinical vs. Academic : If one is choosing a predominantly clinical career op on, then the possibili es include working exclusively privately (in your own clinic or in a group prac ce/poly-clinic), in a corporate hospital or privately-run medical colleges. It is generally said that it is best to ‘learn the trade’ first by working in a team or group se ng before ‘flying solo’. If one were to be ‘tempted’ by the generous ‘deals’ offered by corporates or other similar private ins tu ons, bear in mind what they ‘expect’ from you in return – ‘there is no such thing as a free lunch.’

Government vs. Private : If for whatever reason, exclusively or predominantly private prac ce is not for you, then consider working in the Government sector – which includes ins tu ons such as NIMHANS, CIP, JIPMER, etc or medical colleges (Government). O en these jobs, which are hard to get, offer a good mix of clinical and non-clinical responsibili es including some opportuni es for teaching and research.

Further studies : Academic career op ons include further higher specialist studies/training such as DM (in child psychiatry, addic on psychiatry, etc), a post-doctoral fellowship (PDF) or a PhD. These are fewer in number and higher in demand. Or there might be opportuni es for purely research jobs/careers in India or abroad. As noted, some academic jobs involve teaching, research and some clinical work. On occasions, the rela ve propor on of each of these aspects can be nego ated with your poten al employer.

To emigrate or not : Yet another crucial choice for post-MD psychiatrist is between working in India and going abroad. ‘A rac ve’ countries, at the moment, for further psychiatric training and work include UK, USA, Australia, New Zealand and Canada. One has to remember that none of these countries formally recognise Indian MD degrees and so one will have to virtually re-train in psychiatry – this takes considerable me and effort. If further studies/training is not your objec ve and if working is, then try countries such as Singapore, Brunei, Middle East and so on. Some of the advantages of working abroad are a be er quality of life for you and your family, enhanced work-life balance, financially more rewarding, opportuni es for sub-specializa on, chances to pursue management and leadership roles, reduced volume of clinical work and greater job security. It has to be said that very few of those who emigrate to foreign countries ever return to India for good. Therefore, if one has a family or other important reasons to stay in India, it is best not to consider a career abroad.

Although the discussion so far has been about these apparently dis nct career op ons, this need not always be the case. Some careers (if one were to thoroughly explore) offer just the right mix of what you want. Finally, don’t be afraid to experiment and do not dread change. If something isn’t fulfilling anymore, at whatever stage of the career you are in, try something different – take another route. Be flexible enough to try different things. Life circumstances can change and one’s or the family’s priori es can also change, and this can require you to adapt.

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A workbook exercise

There is something to be said about being business minded. You need to develop basic knowledge about handling finances as well as tricks of running a business, as even the law now subsumes the doctor-pa ent interac on under a consumer-service provider umbrella. It is important to know how to reap benefits of profit and investment so that you can take yourself farther in the profession, and this is especially important if you are planning private prac ce.

Be ready – ‘Believe you can and you are halfway there.’ (Theodore Roosevelt).

Tips on how to plan your career in psychiatry after postgraduation:

Understand what you are good at and what you find intellectually sa sfying.
Find out about various career op ons by talking to colleagues, seniors, friends and through networking (in India and abroad).
Decide whether you are primarily academically – oriented or clinically – oriented. Make a choice, stay focussed and work towards your goals.
Plan for around five years at a me, and re-visit your goals and career progression at regular intervals.
Don’t be afraid of change.

As much as the above sec ons have been about the importance of a career, it is not meant to convey the impression that the only thing important in life is one’s career.

‘A career is wonderful but you cannot curl up with it on a cold night’ (Marilyn Monroe) – The message is – one needs to maintain a healthy work-life balance.

Consider an honest introspec on on the following before choosing a career

Why did you choose psychiatry in the first place?

Can you think of the aspects of psychiatry that you like the most?

Can you think of the aspects of psychiatry that you do not like very much?

Do you like working individually or as a team?

Do you want to be involved in teaching medical students and postgraduates?

Do you want to be involved in a setup that allows for consulta on liaison service?

Do you want to be involved in a setup that is conducive for research and wri ng?

Is there a specific pa ent popula on you would like to see (child, geriatric etc)?

Do you want to see many pa ents on a given OPD day or see less pa ents but in depth for longer?

Which aspect of psychiatry training made you the happiest and felt most meaningful? Where would you like to prac ce -Urban vs semi urban vs rural se ng?

                

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BECOMING A PSYCHIATRIST

Dr. C. Shamasundar

Former Professor of Psychiatry, NIMHANS, Bangalore

Email id : drshamasundar@yahoo.com

Meaning of becoming a psychiatrist. Becoming a psychiatrist is a con nued evolu on of one’s personality, a component of which happens to be professional knowledge. Here, the word knowledge means a resultant of personaliza on of what one has learnt through a process of cri cal verifica on by reflec on and applica on to real life situa ons. This cons tutes as one’s evolving world-view, which in turn keeps re-shaping one’s personality. In addi on, as the nature of stresses and strains in life as well as the process of their management are approximately similar across people, the professional has an enviable opportunity to evolve one’s own status of well-being to the extent that one learns to integrate the ‘objec ve’ (applica on in clinical work) and the ‘subjec ve’ (introspec ve applica on). Acquiring knowledge involves con nuous trial and error learning.

A most important element of knowledge, not generally acknowledged in training and learning is the process of harmonious integra on of sets and domains of knowledge into a meaningful ‘whole’. Though perfect integra on is seldom achieved, the ideal should always be strived for. Such an integra on results in what is conven onally understood as wisdom. Descrip on of a crude example of ‘integra on’: (i) Educa on begins with learning the alphabets one by one. Then, words are learnt by reading le er by le er. (ii) Next, sentences are read word by word. Later, by reading sentence by sentence, the meaning of a paragraph is understood. (iii) Many years later, meaning is con nually and automa cally grasped as one ‘glides’ through the lines of text, only occasionally stopping to read a difficult sentence in detail. This ability is the result of having learnt to integrate hundreds of linguis c components into one holis c process.

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The above example shows that ini al stages of effec ve learning is always by mastering the parts. But, the learning progresses by successively integra ng the learnt parts into a harmonious whole. This in turn is automa cally integrated into one’s personality along with other components like values, a tudes and behavior. Such a holis c personal growth ought to be the objec ves of postgraduate training and learning in psychiatry, wherein professional wisdom is integrated with other components of personality.

Holis c phenomena in mental health and the logical corollaries of this ‘Holism’ are generally neglected in postgraduate training and learning. Almost all areas of mental health knowledge are spread on a holis c con nuum. Four areas of holism are briefly described below as examples so that the profession ac vely and thoroughly explores all other areas for the purpose of training, learning and research.

Psycho-soma c holism: This holism begins at the beginning, the ‘common ancestor’ called zygote.

(a) The zygote undergoes successive divisions and differen a ons, eventually resul ng in various fully developed dynamic systems like, alimentary, cardio-vascular, respiratory, CNS, genito-urinary, etc. These numerous systems are all inter-connectedly, inter- dependently and dynamically integrated into a func onal human being. This is ‘Holism’.

(b) Psychological states are known to influence immune mechanisms and autonomic responses and even gene c expressions. Gene c expressions are influenced by environmental variables. Neuroplas city is influenced by needs and efforts; and ‘efforts’ are obviously psychologically inten oned ac ons like ‘Will’, etc.

(c) The famous popula on survey in Mid-town Manha an in the mid-twen eth century demonstrated a close me-correla on between stressors on the one hand and physical and psychological morbidity on the other. In addi on, severity of the morbidity correlated with the severity of the stress. As the evidences are accumula ng to show that the state of psychological health contributes to func onal recovery and a state of wellbeing irrespec ve of the nature of physical illness, the me is not far off when the whole medicine becomes synonymous with ‘psycho-soma c medicine’, based on ‘psycho-socio- gene co-bio-neuro-immunology’.

The Holism of Resilience is based on homeo-dynamic quality of all living beings..

Resilience is the quality of facing and managing the rou ne tribula ons of life, irrespec ve of the severity of the stressors. Thus, resilience is a product of and contributor to con nued trial and error learning of one’s coping-skills (or life-skills).

(a) In humans, homeo-dynamic processes occur at three levels. (i) Immune and related systems at the physical level. (ii) A tudinal and behavioural components of coping-skills atthePsycho-sociallevel. (iii)Neuroplas cityatthelevelofcentralnervoussystem.

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(b) Homeo-dynamics at all three levels require feed-back loops. More complex the organism, more complex the feed-back system. Even ar ficial intelligence (‘machine- learning’) is dependent on extensive and complex feed-back circuitry. The behavioural equivalent of feed-back loops is the process of trial and error learning with con nuous self-monitoring (or self-audit).

(c) Just as the immune system learns to manage infec ons only a er being exposed to them, coping-skills are learnt only by being exposed to rou ne stresses and strains of life. Similarly, neuroplas city is dependent on func onal needs and inten onal effort.

(d) It means that an individual who has not been exposed to germs, injuries, pain, anxie es, depression or life’s challenges, etc. will not have learnt physical, psycho-social or neurological resilience. In other words, development of resilience needs opportuni es from birth onwards to face challenges and manage them by trial and error learning in a caring environment. Thus, one can visualize a con nuum of a healthy individual being a product of a healthy family, which in turn is a product of healthy social-culture.

(e) A corollary of the above descrip on of coping is that the conven onal concepts of ‘pathology’, ‘psychopathology’ or ‘neuropathology’ are not abnormali es. They are ‘normal’ coping responses, the final effect being either reversible or irreversible. Thus, any illness, either physical, psychological or neurological is essen ally a result of inadequate resilience (coping) or extreme stress. Therefore, the ideal objec ve of any mode of clinical management or interven on is to restore and strengthen the individual’s coping (resilience).

(f) Some of the personality quali es required for a robust coping are fairness, trust worthiness, personal discipline and courage, etc. They happen to be components of human values.

Holism of Human Values. This holism is related to the fact of the ini al ‘One’ becoming the later ‘many’ of existence, irrespec ve of cause, either Divine or Naturally cosmological. In terms of a tudes and behavior, this holism has a few corollaries.

(a) The individual is accountable to the eco-system at large and to humanity in par cular. For example: (i) ‘Righteousness’ in Indian scriptures means those a tudes and behavior which contribute to welfare of all crea on. (ii) One of the five principles of Ayurveda’s concept of total health is the individual’s posi ve contribu on to human welfare. (iii) One of the highest of human virtues is to help a fellow human in distress. This happens to be the objec ve of medical profession.

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(b) Almost all interpersonal conflicts result from viola on of human values. For example, there is no human who likes to be cheated, insulted or violated upon, etc. Even criminals do not like their own personal welfare violated upon. How strong should the mental health professional’s own personality be in respect of these values?

(c) In addi on, many of these human values also happen to be ‘desirable therapist quali es’ that posi vely correlate with therapeu c outcome. Besides, psycho-social modes of managements are the most required forms of management for the following reasons: (i) Pharmacological modes of management are effec ve only in approximately 33% of instances. (ii) Almost all psycho-pharmacological agents are CNS-depressants, interfering with trial and error learning necessary to learn coping-skills. (iii) Thus, injudicious use of pharmacological agents and their overuse leads the pa ents and their families to suffer dis-use atrophy of their coping-skills or resilience.

Holism of learning

(a) We are all very familiar with methodologies of ‘objec ve’ learning about phenomena ‘outside of ourselves’. What is the instrument of the above ‘objec ve’ learning? That instrument is the mind, irrespec ve of its defini on.

(b) We all know that the natural scien sts always strive to narrow down the error (‘bias’) of their instruments to the barest minimum possible, by regularly calibra ng their instruments.

(c) To what extent are we the mental health professionals preoccupied with regularly or con nuously calibra ng our own instrument of knowledge, learning and experience? How to calibrate this instrument, except by applica on of our knowledge to our own minds, a tudes and behavior?

(d) Therefore, all mental health professionals are to be taught to introspect and apply the learnt psychological and sociological concepts to their own life and verify their validity in real life se ng. Such a learning should run parallel to what they keep learning through their pa ents in the clinical se ngs. That is, the learning has to be both objec ve and subjec ve, both requiring corrobora on with each other

(e) If and when such an introspec ve learning becomes a part of standardized postgraduate teaching and learning, hopefully, such neglected components of wellbeing as ‘Willed’ effort (inten onal effort), etc. would become more important components of clinical management.

Concluding remarks

The foregoing text briefly describes few examples of holism. I believe that, integra on of knowledge of all areas of mental health will eventually turn out to be holis c. Another area of holism, the diagnos c range, is crudely represented in the two figures below.

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ORGANIC EXPRESSIONS

    

Normal Person

  

NEUROTIC-AFFECTIVE EXPRESSIONS

  

PSYCHOTIC EXPRESSIONS

FIGURE-1: Diagrama c representa on of the con nuum in the diagnos c dimension as a consequence of homeo-dynamic holism. The results of op mal adjustment within one-self and with the environment by an ideally healthy individual places him at the centre of the diagnos c-space.

Notes : (1) The responses are on mul ple diagnos c con nua, (2) Thus, ideal diagnos c criteria are seldom met. (3) Ideal health is circle at the Centre. (4) When the homeo- dynamic adjustments fail to whatever degree, the ‘posi on,’ ‘shape’ and size of the individual varies as shown in FIGURE-2 on the next page.

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PERSONALITY EXPRESSIONS

FIGURE-2 : (Ref: Figure-1) Figura ve display of examples of how different mentally ill persons (shaded area) generally exhibit admixture of and overlapping of clinical features of different diagnos c categories.

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PERSPECTIVE OF RESIDENTS

Senior resident

Dr. Deepali Bansal,

Senior Resident, Cosmos Institute of Mental Health and Behavioral Sciences, Delhi

Email id : deepalibansal.dr@gmail.com

Do’s and Don’ts during postgraduate training in psychiatry

1. Do not forget your neurology and medicine. Ruling out organicity in psychiatric pa ents is as important as giving the right medicine to the pa ent. It goes a long way in dras cally increasing the quality of pa ent care as well as enhancing the therapeu c sa sfac on of the trea ng doctor.

2. Do not get overwhelmed by the ambiguity of the subject. The boundaries in psychiatry may seem nebulous at first, but always approach and prac ce psychiatry like a science. One can take the help of guidelines, algorithms, standardized texts wherever necessary.

3. Do not undermine the value of team effort. The role of a clinical psychologist and psychiatric social worker is crucial for the complete recovery of the pa ent. The trea ng psychiatrist must be a team player along with subtle leadership quali es.

4. Do not think that you are invincible to mental health issues. Being a cardiologist doesn’t make a doctor immune to myocardial infarc on. Similarly reading and prac cing psychiatry doesn’t guarantee immunity from depression, anxiety, OCD or any other psychiatric disorder for that ma er. Appropriate and mely interven on must be taken wherever necessary.

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5. Do not get disheartened by the pa ents who are difficult to cure. Certain diagnoses like substance addic on, personality disorders can be frustra ng when it comes to ini al treatment outcomes, but one must prac ce the goal of harm reduc on and holis c improvement of pa ent’s quality of life.

6. Ac vely avoid ge ng fixated on one diagnosis or one pa ern of treatment. While one must be confident about one’s skills, at the same me one must recognise the wide horizon of possibili es that are prac sed in other places, na onally and interna onally.

7. Always remember that learning will and must con nue. Residency is just the beginning of a lifelong learning process and many more skills are acquired a er the third year of residency. One must ac vely keep their mind open towards clarifying the doub ul areas, as well as ge ng hold of the newer set of ideas and treatments.

8. Indianize your prac ce as much as possible. Try to find relevant Indian data in psychopharmacological as well as psychotherapeu c area. One must ac vely look out for the fact whether a par cular research included any Indian or South Asian subjects. Do not get bewildered by our pa ents responding to different dosages of medica on than what is given in a guideline or standard text. Also, always take the sociocultural fabric of Indian pa ent into considera on during psychotherapeu c interven ons.

9. Start paying a en on to the medicolegal aspects of psychiatric prac ce during residency itself. Once out of medical college, a psychiatrist is expected to know the ni y gri y of the new Mental Health Care Act, 2017. Being new in prac ce doesn’t excuse one from the medicolegal responsibility of prescribing narco cs, involuntary admissions, and so forth. For those planning to prac ce psychiatry in a private se ng, this becomes even more important.

10. Be tech savvy. In the era of cyberchondria and Internet addic on, a Psychiatrist must know how to use Internet for the maximum benefit of the pa ents. Use of various apps and online tools can assist in diagnosis as well as treatment of mental health pa ents. This is the unexplored area in psychiatric prac ce with a huge therapeu c poten al. Never hesitate to propose ideas to consultants or learn from the pa ents about what be er can be done with the mobile phone and Internet for be er mental health.

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Junior Resident

Dr. Ajay Thomas Kurien.

Junior Resident,
St. John’s Medical College Hospital, Bangalore

Email id : ajaykurien91@gmail.com

Being a postgraduate in Psychiatry is the right me to inculcate and develop a ributes which will go a long way in the making of a good psychiatrist. More o en than not, many of us get lost in the rat race of daily rounds, running busy outpa ent departments, discharge summaries and preparing presenta ons for academics that we don’t pay a en on to the quali es that form the backbone of this profession.

Pa ence : Pa ence is a virtue which will dis nguish yourself as an exemplary psychiatrist compared to others. Being a postgraduate, where you are the first line of care for the

pa ent and family members on a daily basis, it is vital to have abundance of pa ence to educate and explain the treatment as well as to clarify any queries that they might have. This will help you win over the confidence of the pa ent and the family members you deal with. It is also important to have pa ence with the treatment process yourself as the results in psychiatry take much longer to manifest as compared to most other medical speciali es.

Silence : The moments of silence spent in ac ve listening and observa on are crucial parts of interviewing a pa ent. In the process of establishing rapport, the importance of le ng

thepa enttalkwhileensuringtheyhaveyourrapta en oncannotbeundermined. This includes avoiding interrup on of the interview with phone calls, tex ng or even wandering off in thought. Even the most guarded pa ents tend to open up once they know they have your undivided a en on.

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Yearning to learn : During the phase of postgradua on, you always have your seniors and consultants to fall back on while making treatment decisions. This should in no way deter

the process of self-learning and mo va on to keep yourselves abreast of the recent advances and research findings. The best way to consolidate learning is to go back and read about what you see first-hand in the pa ents under your care, formulate a plan of treatment and then to take part ac vely in the discussion with regard to the choice of treatment. The yearning and passion to learn has to be a lifelong process in order to ensure the best possible care for the pa ent.

Commitment and Care : Commitment to the profession will help the postgraduates to see all the hard work they put in as a ‘calling’. This will help to assign a personal meaning to

the work which will in turn lessen the chances of burnout. A postgraduate must be able to make the pa ent feel that they are being cared for and that their difficul es are being heard. Most o en pa ents care about how much their doctor cares for them than how academically brilliant they are.

Humane : The postgraduates must not forget to add a human touch in all their dealings with their pa ents. The most important part is to look beyond the pa ent as being

informa on on charts or a list of medical problems. It is crucial to understand each pa ent as a whole person with their hopes, aspira ons, fears and priori es. Adop ng a non- judgemental stance while maintaining respect and regard for the pa ent’s needs and preferences is much needed.

Interest in the subject : The more interest a postgraduate has for the subject, the more efforts he will put in to expand his knowledge and competence. When a postgraduate

takes ac ve interest in learning, there will always be others especially seniors and consultants who will help facilitate the process. A ending and presen ng at conferences and con nuing medical educa on mee ngs will help expand the horizons of knowledge beyond the textbooks.

Awareness : Awareness about the important laws and legisla ons related to mental health care is necessary to safeguard the interests of the pa ents under your care. In this

age where medical profession is being increasingly brought under li ga on, the postgraduate must be aware of the legal implica ons and provisions related to mental healthcare. This will aid in effec ve communica on with the pa ent and family members which should always be followed by thorough documenta on. A postgraduate should also keep himself aware of the possible drug interac ons and side effects, taking efforts to read up those which are not known, which can protect the pa ent from avoidable suffering due to drug reac ons.

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Time : A postgraduate must be able to manage me effec vely in order to ensure that some me is set apart for self and family. Taking breaks in-between and spending me

unwinding and relaxing is a must-do for mental well-being. Looking a er self is paramount to looking a er others. Some ac vi es that help de-stress and put you back in tune with the world are a much-needed element of postgraduate life.

Risks : The postgraduate must be able to gauge and understand the risks involved in dealing with pa ents who are agitated, violent or suicidal. Personal safety must at all

mes be ensured before dealing with a vulnerable pa ent. The strategies to manage such circumstances must always be at the back of the postgraduate’s mind since in most of these situa ons, other staff including security personnel turn to the psychiatrist to deal with the pa ent.

Yielding to empathy : A postgraduate must strive to understand what the pa ent and the family is going through and how much the illness is affec ng every sphere of their life.

When the pa ent and the family is grappling to come in terms with the reality of their illness which is o en s gma sed by the society, an empathe c approach by their clinician can become the best star ng point to restore their confidence.

The best approach to follow, to ensure that you become a good psychiatrist at the end of three years training, is to pay a en on to PSYCHIATRY.

“Cure sometimes, treat often, and comfort always.”

— Hippocrates

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AWARD WINNING PSYCHIATRISTS

A brief reflection by Dr. Supriya Mathur, Senior Resident, Department of Psychiatry, Jaipur National University Institute for Medical Sciences and Research Centre, Jaipur

Email id : supriyamathur22@gmail.com

1. DR. BHARAT VATWANI

Medical Profession is undoubtedly one of the noblest of professions and most of the students who choose it as a career con nue working hard day and night, despite experiencing the hardships they face in their professional career and the toll it takes on their personal lives. In spite of having an innate desire to heal and serve the society, these obstacles may some mes cause a burnout even in the most driven of the students. In mes such as these, there arises a need to look up to someone for mo va on. One of the people who bestow upon us such mo va on is the winner of the pres gious Magsaysay Award 2018, Dr. Bharat Vatwani.

A chance encounter led to the establishment of Dr Vatwani’s rehabilita on founda on. Hesawamandrinkingoutofagu erwiththehelpofanemptycoconutshell. Theman was suffering from schizophrenia. While this man remained tangible yet invisible to the busy society around him, Dr Vatwani and his wife, Dr. Smitha offered to help. They brought him to his centre, groomed him and started his treatment. When the pa ent improved and started to interact, he informed that he is a science graduate. He gave them his address and was then reunited with his family.

Few years later, the doctor couple formed Shraddha Rehabilita on Founda on, at Vengaon Village, Maharashtra in 1989. This founda on helps such “wandering” pa ents by trea ng them and offering them a temporary home. Once pa ents improve, the founda on tracks down their families and try reuni ng them. With a success rate of 98%, the founda on has helped reuni ng about 7000 pa ents ll date, some of whom belonged to as far as Nepal. Dr Vatwani stresses upon the lack of awareness and empathy toward mental illness and hopes that the Magsaysay Award will reduce the s gma.

101

Hisstoryisinspira onalinsomanyways. Inaworldwherepeopleseekmonetarygains and fame in a short span of me, Dr. Vatwani with the help of his wife and few other people, works day and night for people who have been ignored and ill-treated, people who have been shunned by their own family and rela ves due to social s gma, people who need medical support, social and mental support – pa ents with Mental disorders. All this started with a small observa on which most of us may ignore, an observa on which occurred outside of his “duty hours” while he was having his “personal me”. This reminds us that being doctors, we need to extend our services even outside our working hours and adhere to the Hippocra c Oath. It is not just a ma er of being intelligent and prescribing medica ons but also being diligent and having the drive, honesty and empathy which can help people and in turn help in the be erment of the society.

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2. DR. VIKRAM PATEL

Another legend who has always mo vated us is the renowned Psychiatrist Dr Vikram Patel. ListedasonefortheWorld’s100mostinfluen alpeoplebyTimeMagazinein2015, he is a Professor of Interna onal Mental Health and the Wellcome Trust Senior Clinical Research Fellow at the London School of Hygiene and Tropical Medicine. He was awarded the Chalmers Medal by the Royal Society of Tropical Medicine and Hygiene (UK), The Sarnat Prize in mental health by the Ins tute of Medicine (USA), and most recently the Canada Gairdner Global Health Award. Although his major focus is on Community Mental Health, his works extend to Epidemiology, Psychology, Disability, Child development, Public Health and Substance abuse. He is the Co-Founder and former Director of the Centre for Global Mental Health at the London School of Hygiene and Tropical Medicine (LSHTM) and the Co-Director of the Centre for Control of Chronic Condi ons at the Public Health Founda on of India.

In 1997, Dr. Patel and his few colleagues formed an NGO called Sangath in Goa. Sangath works with London School of Hygiene and Tropical Medicine in the area of child development and mental health. In 2008, Sangath won the MacArthur Founda on’s Interna onal Prize for Crea ve and Effec ve Ins tu ons which has helped toward the vision of the founda on which seeks to innovate solu ons to improve mental and physical health across the life course along the values of Passion, Performance, Excellence, Team work, Empathy, Respect, Integrity and Innova on.

Dr.Patelhasbeenaninspira onsincetheearlyyearsofhiscareer. Understandingthelack of resources, he has strived towards empowering society to intervene at the community level, and what remains extraordinary about it is the way people are educated about mental illness in an easy to understand vernacular language. It is important because caregivers are usually not well aware about mental illnesses and are perplexed by pa ent’s condi on and behaviour. An understanding and empathe c approach towards the illness on the part of the caregivers helps in a be er treatment.

The medical profession s ll remains one the hardest career choices. It is difficult to get into, difficult to get by and even more difficult to prac ce with all zeal and integrity and yet somehow people like Dr. Vikram Patel go out of their way and establish such touchstone of excellence and service to mankind which leaves the future genera on of doctors thrilled and mo vated.

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3. Dr M. Sarada Menon

“Look at a person with mental health problems as a human being, and then everything will change”

A statement that puts everything in the right perspec ve for a Psychiatrist. A statement that makes you revaluate your approach towards a pa ent and the way she is perceived by the society. Such inspiring words ought to be said by a legend in the Psychiatric world, Dr M. Sarada Menon, the first female Psychiatrist of India.

Born on 5th April, 1923 in Mangalore, Karnataka, Dr Menon graduated in medicine from Madras Medical college in 1951. She completed her Diploma in Psychiatric Medicine from NIMHANS in 1959 thus becoming the first female Psychiatrist in India. Since the beginning of her career she spearheaded the drive towards helping the mentally ill. She ini ated several reforms in the hospitals she worked in like opening of a Psychiatric Department, a dedicated Psychiatric OPD etc. On the personal front, not only she mo vated ini a on of par cipa on of social organiza ons in the rehabilita on of mentally ill pa ents like AASHA (a community-based organiza on assis ng the families of mentally-ill people based in Chennai) but also she converted one of the rooms in her residence into a shelter and later influenced the local chapter of YMCA to open pallia ve care centres.

In 1984, she founded Schizophrenia Research Founda on (SCARF), a non-profit NGO, for the rehabilita on of people suffering from schizophrenia and other mental diseases. SCARF provides temporary shelters and telepsychiatry therapy. It also runs a voca onal training centre aimed at the rehabilita on of pa ents and manages a mobile clinic. Dr Menon has also served as the vice-president of the Chennai chapter of the Red Cross Society and has been a member of the state government panel set up for proposing prison reforms. She is also associated with the World Fellowship for Schizophrenia and Allied Disorders (WFSAD).

For her exemplary work in the field on mental health, Dr Menon was awarded the Padma Bhushan in 1992, Best Doctor Award from the Government of Tamil Nadu, Best Employer Award from the Government of India, Special Award of the Interna onal Associa on of Psycho-Social Rehabilita on, Boston and the For the Sake of Honour Award from the Rotary Club, Chennai. And recently in 2016, the Government of Tamil Nadu honoured her again with Avvaiyyar Award.

At the age of 96 today, Dr Menon is s ll ac ve and highly mo vated towards the work she has been doing for the past six decades. She stands as an epitomic pillar of mo va on and women empowerment, guiding and inspiring the future genera on of Psychiatrists towards building a be er and more empathe c society for the mentally ill.

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PERSPECTIVES IN PSYCHIATRY TRAINING WHAT EVERY POSTGRADUATE MUST KNOW

Dr. Suhas Chandran MD., Dr. Kishor M . MD

Psychiatry is a fascinating specialty and learning professional skills encompasses both science and art, at every stage. Although there are numerous textbooks for postgraduate students in psychiatry, hardly few books explore the subtle nuances of psychiatric training and skills that could help the resident approach psychiatry in a holistic manner.

Keeping this in mind, this book is for psychiatry postgraduates & those graduates who are keen to take up psychiatry, written by seniors sharing their experiences on clinical work, academics and research among others that lie ahead in the psychiatry residency. The objectives are to provide students with information,strategies and resorces in psychiatry as they adjust to the milieu of post-graduation.

Exposure to such material in these formative years can help the student to develop complex thinking skills, expand their thought process, and help prepare them for their future life as a professional. With topics ranging from ABC of Psychiatry to self-monitoring, every enthusiastic reader is likely to take away something be interesting and useful from this book

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