My life as a Psychiatry Registrar

What stage of your training are you at?

I am currently an ST4 in General Adult Psychiatry working LTFT at 80%.

What region are you working?

I am in the South London & The Maudsley Training Programme, which provides placements within the South East region of London.

What stage did you decide on your speciality & what other specialities were you considering?

At medical school I adored anaesthetics and spent as much time as I could during my placements gaining anaesthetic experience.  I found this beneficial not only for developing specialist skills, but also for mastering the basics of any medical career:  airway management, fluids and being able to cannulate anything that moves!  I qualified at Barts and The London and was very lucky to have an inspirational team of anaesthetists on my doorstep at The Royal London Hospital.

Sadly, during my FY1 year, I had a recurrence of the cancer that I had fought in my second year of medical school and I was forced to take time out.  I realised that the treatments had left me with chronic health problems and that I would have to seriously consider my further choice of career.  I suffered with chronic fatigue and the day job became increasingly difficult, not to mention the on-calls.  I felt at this point that anaesthetics, though I still loved the discipline, would be a tough career choice for me and I was forced to reconsider.  I’d also be lying if I didn’t admit that the thought of the Physics based exams wasn’t terrifying the life out of me!

I really enjoyed my time in Psychiatry at medical school and did another firm during FY2 which reassured me that there is a way to have a medical career without being in the cut-and-thrust environment of an acute medical or surgical team.  The staff I met convinced me that Psychiatry had a good work life balance and that training is flexible to individual needs.  I had a natural affinity for the nature of the work and had been praised throughout FY for excellent communication skills.  I started tailoring my CV and applied solely to Psychiatry for CT, as I knew it was the only discipline I had a serious interest in pursuing.

What brought you to your decision / Any deciding factors?

As previously mentioned, my health was a major deciding factor in choosing my speciality.  However, it was also apparent, both in my firms at medical school and my FY2 post, that I thrived in this environment.  I found it immensely easy to communicate with patients that my colleagues would struggle to engage and found that I could empathise with and contain those who were in profound distress.

I had a natural interest in Psychiatry due to obtaining a Psychology degree prior to starting medical school and working in a forensic post as an Assistant Clinical Psychologist.  However, during this time I developed a real interest in Psychiatry and it was this that originally prompted me to apply to medical school and re-train.  You could say, therefore, that Psychiatry would always be my default career path, but I truly found a passion in anaesthetics.  I still regret being unable to take that path, but feel ultimately that I am most naturally adapted to the path I have chosen.

How have you found the exams so far? How did you revise for them?

I was very lucky to pass all of the MRCPsych exams first time and found them relatively hassle free.  Having said that I had a major bonus in having done a Psychology degree, which established a firm base in theory, research and statistics.

I started revision for each exam 3 months prior and used revision and question banks such as SPMM and MRCPsych Mentor.  For CASC I had a study-buddy at the same level and we practised scenarios until we were sick to death of them!  Roping in various long-suffering SpR colleagues as our ‘challenging’ patients. By the time the final CASC exam came around we were ready for any challenge that could be thrown at us.

Since completing the exams I have undertaken revision sessions to help fellow CT colleagues and would recommend this as a great way to consolidate your knowledge and build a teaching portfolio.

How is your day job split up?

I currently work LTFT at 80% in a Community Mental Health Team and work Monday to Thursday.  Three days a week are clinical and are generally spent running clinics and attending the MDT.  I accommodate emergencies within these slots, doing visits with colleagues or attending mental health act assessments.

Each Wednesday I attend my special interest day at the Place of Safety in the Maudsley.  This is mostly dealing with patients who have been brought in under section 136 and conducting the first recommendation for a mental health section.  The special interest day is protected in Psychiatry and all trainees must not be in their clinical place of work on these days.  To safeguard the arrangement the salary for these sessions is paid by the Deanery.

In addition, as a SpR, I attend a Calman Day once a month at The Maudsley. This is an educational day for SpRs arranged by our colleagues on topics that we may find interesting.  Psychiatry as a discipline has an excellent record of providing training to their trainees and properly safe-guarding their time.

What aspects of being a psychiatry trainee have you enjoyed the most? What has been hard?

The thing I have enjoyed most about Psychiatry is the variation in training. I consider myself very lucky to have completed my CT in South-West London before moving to South-East London for my ST.  The calibre of these hospitals has meant that I have had access to a lot of services that are highly specialist in nature and, in some cases, the leading expert on a national level.

Generally, Psychiatry appears to be a division between community services and acute inpatient hospitals.  This is far from the truth. There are five different divisions in ST training alone: forensic, old-age, general adults, child and adolescent and psychotherapy. This means that there is plenty of opportunity to experience different areas and find your niche.  Almost every person I know in training has an area that they love and an area that they really can’t stand.  For my part, I love the high adrenaline areas where you can yield quick results with the most challenging patients, such as Intensive Care Units or Crisis Intervention / Home Treatment.

The hardest part for me has been the consistent reduction in funding to mental health services.  Working in this area is stressful and there is a high incidence of burnout.  It is becoming increasingly common to see members of staff to leave their post and for that opening to never be refilled, putting additional stress on those who remain.  Multiple services are being discontinued so that teams collapse into one service that cannot hope to provide the same standard of care.  The extent of this lack of funding has meant that I have had to develop a tough exterior in the face of extreme distress. It is hard to glean job satisfaction when your patients feel that you have failed them.

What’s the best and worst aspects about psychiatry training?

The best aspect is that psychiatry training really appreciates the work-life balance.  Many trainees are LTFT and the training programme is really quite flexible in accounting for individual needs.  I have required multiple adaptations to my training over the years and this has always been handled with the minimum of fuss.

The worst aspect is probably the same as any other discipline:  the portfolio.  I feel that the process constantly requires you to jump through hoops for the sake of completion.  Although this is good for documenting experience and ensuring everyone theoretically meets the same standard, I still feel that it is weak overall in identifying those who are struggling.  Sometimes the nature of the portfolio and ARCP makes you feel like you are a mouse on a wheel. For the last six months of my CT training I had completed all ARCP requirements, but remained in post until I moved to ST.  I can honestly say that this was the most enjoyable time of my training and allowed me to concentrate on what I was really interested in.

Could you share with us your most challenging moments?

Ironically, considering my background in Psychology, the most challenging part of training for me has been the psychotherapy competencies.  As I realised all those years ago, I am simply not drawn to this area of Psychiatry.  The time scale for completing the competencies is quite tight and has to be obtained in different disciplines.  I struggled with the Psychodynamic model and found it challenging to undertake a 40 hour commitment with a patient.  I often feel that this is the main part of my training that feels like ‘going through the motions’.

Another challenging area, that is a regular occurrence, is the decision making in high risk cases.  Suicidality is common in Psychiatry and it is not always easy to judge the individual or the risks.  The reduction in funding has meant that there are far fewer beds available and that there are often individuals that simply can’t be detained or admitted.  Learning to live with this uncertainty and being able to sleep at night is part of the job and you have to be able to do what you can to ensure that person’s safety, while also accepting your limitations.

What do you think are the most critical personality traits that a doctor should possess for a career in psychiatry?

Critical factors are a genuine interest and curiosity towards others, alongside an ability for empathy.  You need to be resilient in being able to process not only the patient’s presentation, but also the nature of their disclosure.  It helps if you are a non-judgemental person, or at least introspective of the nature of your prejudices, as you will experience all walks of life, including serious crimes.

Another factor, peculiar to Psychiatry, is an ability to be flexible.  Psychiatry is not as concrete as other areas of medicine and it can often be difficult to reach a diagnosis or formulate a specific treatment plan.  The patient has to be seen as an individual and, although there is a general model for treatment, the psychiatrist must be flexible in creating an individualised treatment plan.  An ability to experiment with different treatments in the face of uncertainty is crucial.

Can you tell us about any interesting breaks or side projects you have taken during your training? How did you organise these?

I have not taken any breaks from training, although I have had periods when I have been off to recover from surgery.  The longest of these was 3 months and I authored a research paper during this time, which was published last year.  I was lucky to be given a project by the Drugs and Therapeutics Committee at my Trust, who had a data set for a project, but nobody to analyse or author the paper. I gained a national prize for my efforts, which greatly enhanced my scores at ST interview.

What’s your number one piece of advice to junior doctors who are considering applying for psychiatry training?

Psychiatry is vastly different from any other area of medicine and I would encourage potential trainees to arrange taster sessions or an FY post in order to get a real feel for the job.  This will quickly demonstrate whether you have the personality to thrive in that environment and demonstrate interest.  If this is not possible try highlighting your psychiatry experiences in other areas i.e. portfolio reflection on dealing with a patient who has overdosed during a take; breaking bad news and communication during a difficult diagnosis.  The application to specialty training is to demonstrate your interest, so you can be flexible in drawing your experiences from different areas.  Psychiatry, after all, is present in all walks of life and at all times.