Dr Soh Keng Chuan
My Training Experience at the Department of Psychological Medicine, National University Hospital (Ward Rotation)
Having just finished my year of housemanship, I joined the department in May 2009 as a newly turned medical officer, with a keen interest in the field of Psychiatry. Despite my inclination towards the discipline, I had minimal prior experience in the management of psychiatric patients. The department was savvy to the varying experience levels of medical officers and able to cater to our needs at different stages of our training. I was assigned to a ward rotation, to help care for the hospitals psychiatric inpatients.
The psychiatric inpatients offered a rich variety of learning materials, with adequate volume to keep one gainfully occupied, yet without being overwhelming to cause one to be swamped.
Ward consultants are both available and approachable, to take medical officers through the cases from admission to subsequent discharge. Medical officers are given fair exposure to the duties involved in caring for patients with psychiatric conditions in an inpatient setting, from obtaining corroborative history from family members to arranging the necessary social support systems to prepare patients for going back to life outside of the psychiatric wards.
At the same time, these inpatients had primarily psychiatric issues, but classifying diseases as such was artificial at best. In a general hospital setting, there was a fair amount of medical comorbidities, which required clinical acumen to determine whether the breathless patient was having an asthmatic exacerbation or a panic attack, whether the confused, forgetful patient was depressed, demented or perhaps even delirious. The range of cases also allow for overlap of care with other medical/surgical disciplines, where appropriate.
Grand Ward Round Presentations
Challenging cases best highlight the need for a multidisciplinary approach towards the management, and medical officers are, at times, required to present some of such cases of learning value to the rest of the department.
Live interviews with the patients are sometimes conducted, with the patients’ approval, allowing the departments staff to have a better firsthand idea of the patient and directly clarify certain doubts they may have with the patient.
The process of preparing allows the medical officer to familiarize oneself with details of the cases, and the input of other healthcare workers with varying perspectives often provides useful contributions towards the care of these patients.
The medical officer working in the ward will quickly come to see that pharmacological treatments are merely one of the treatment modalities available. Whilst some might feel uncomfortable with taking on psychotherapy alone for selected patients, the department’s psychologists are more than happy for doctors to sit in with them for their therapy sessions.
I had asked to sit in for some of the cases, and the therapists graciously tried their best to accommodate my timings to see the patients together. After the sessions, they took the time to discuss the cases with me, and this helped me to feel a lot more involved in the holistic care of the patient, and better equipped to take on psychotherapy by myself in the future if need be.
A ward rotation does not limit the medical officer to seeing inpatient cases. Ward Medical Officers also run a MO clinic on a weekly basis, where they sometimes follow up on cases discharged from the ward and other patients with relatively more stable psychiatric conditions.
There are weekly Journal Club sessions, which help the medical officers to keep up to date on various topics by means of article reviews, debates, or sharing sessions by external guest speakers.
Medical officers also get supervision in the cases they see at emergency whilst on duty and a better insight on psychiatry for child and adolescents, from other weekly teaching sessions.
The posting was helpful for me in establishing a foundation in caring for psychiatric patients, under adequate supervision. The variety of cases to learn from offered good mental stimulation, and I would recommend a posting at the Department of Psychological Medicine at National University Hospital to residents deliberating over where to choose for their training rotations.
Dr Surej John
Department of Psychological medicine
National University Hospital
When I joined NUH after completing my basic training from Edinburgh, Scotland as an Advanced Specialist Trainee, I was apprehensive about the quality of training and opportunities available in a small country like Singapore. Having worked here for over 18 months, I am glad that I made the right choice by coming to Singapore. I am also glad that I chose the right hospital in Singapore to continue my training.
Our department (Department of Psychological medicine) is a medium sized unit with over 7 full time consultants, several part time consultants, 3 registrars and 6 medical officers. Training is offered mainly in General adult and old age psychiatry as well as Consultation Liaison psychiatry. We also have part time consultants offering child and adolescent psychiatry as well as addiction psychiatry services. My postings so far have been in Consultation liaison psychiatry and in Inpatient psychiatry.
Consultation liaison psychiatry in NUH offers the opportunity to observe and learn from a wide spectrum of cases. I have done consultation liaison psychiatry earlier in Edinburgh as a medical officer, but the Liaison psychiatry in NUH was a different experience altogether because of the variety of cases you get to see every day. I had the opportunity to manage and learn from a variety of neuro-psychiatry, psycho-oncology, psycho-cardiology or psychiatric-endocrinology cases apart from the regular assessments for depressive illnesses or dementia. I also become adept at doing suicide risk and capacity assessments. The unit also has a teaching round every Tuesday morning where one is expected to present or discuss relevant topics with regard to Consultation liaison psychiatry. Overall it can be described as a busy but a thoroughly enjoyable job where you go back home fulfilled after learning something new, every day.
Our psychiatry inpatient ward is not as big as some of the other hospitals in Singapore. However, we have a fully functional multi-disciplinary team consisting of occupational therapists, art therapists, psychologists, community rehab team, medical social workers and nurse clinicians apart from regular doctors and the nursing staff. It is a 26-bedded unit, which is full around 80% full of the time. Ward 12 is a great place to work especially because of the friendly staff and their relaxed attitude. Apart from managing regular psychiatric cases such as psychosis or depressive illness, I had the opportunity to manage some challenging sub specialty cases from neuro-psychiatry or psycho-oncology. I also learned a great deal about prescribing for the medically unwell patients. The multi-disciplinary approach helps you to appreciate the work our para medical colleagues perform to help our patients. Weekly multi-disciplinary ward rounds are a great way to integrate the treatment provided for a patient as they help you look at managing these complex conditions beyond a medical point of view. There is also a dedicated child and adolescent psychiatric service, which works closely with the pediatric department. They also offer the option to sit in during assessments and learn from senior colleagues. Occasionally we also get the opportunity to manage adolescents in the psychiatric ward under the guidance of child and adolescent psychiatrists.
Research and academic activities are given a great deal of importance in the department. Weekly grand ward rounds have helped me to learn about managing challenging cases and attending journal clubs helped me to keep abreast with the latest developments in psychiatry. The opportunity to make presentations at many of these meetings also helped me to furnish my presentation skills. There is a great deal of discussion at these meetings, which are constructive and enlightening. I particularly enjoy our psychotherapy interest group where cases are presented and discussed from a psychological point of view. I am fortunate to have spent time with my supervisors where they helped me to identify my strengths and weaknesses. They also took out time from their busy schedules to guide me in the right career path. In comparison to some other units I have worked with in the past, research here is given a lot of importance. My supervisors guided me with a lot of patience through every step of my research studies.
The senior doctors are friendly and approachable and they each have plenty of research and clinical experience behind them. The department is multi-cultural and we have doctors trained from all around the world. I have learned a great deal from interacting with each and every one of them.
Overall, NUH offers a great environment for working and training. I cannot see myself working anywhere else but here.
Dr Emily Ho
Department of Psychological medicine
National University Hospital
My training experience in National University Hospital, Department of Psychological Medicine
My first encounter with psychiatry was in NUH when I was a medical student. Although it was a very short rotation in the department, they were able to make me feel like a member of the family. Hence, for my first Medical Officer posting, I chose to return to the department. My interest in psychiatry grew as I was guided with close supervision from the enthusiastic tutors and the many friendly and approachable allied health members.
Practicing psychiatry in a general hospital has more benefits than I could list here. The range of cases never fail to amaze me, and my interest grew as I learnt to manage cases ranging from the mild cases of adjustment disorders, mood disorders, schizophrenia which even include catatonic schizophrenia, to complex cases with multiple medical problems and organic causes. I also had the privilege of working closely with the other departments in NUH including neurology, paediatricians and geriatricians for our child and adolescent as well as elderly patients, and those with medical problems. These discussions, guidance and teachings were invaluable, and with all the professional advice given, we learn to face new challenges and achieve a greater sense of satisfaction.
Psychotherapy is a field where learning has to be through experience and close supervision. I was fortunate to be able to select my own patients for psychotherapy and work closely with the psychologist. I was also given many opportunities to present and discuss my cases during the weekly psychotherapy interest group, where I gather great insight into my cases.
The guidance and hands-on experience for the different procedures such as electroconvulsive therapy has made me confident of conducting the procedure independently within a short period of time. Of course, knowing that help from the seniors is always available makes me feel at ease in seeking advice at all times.
The interest in research in the department has allowed me to explore my own interest in this area. There was no lack of cases to stimulate ideas for research. I was allowed to present my ideas so that everyone in the department can brainstorm and fine-tune it. There was more help and advice than I could ask for from the various colleagues who were trained in research.
After doing my various rotations, I have chosen to return to this family. I am still very glad for the guidance from the various seniors, including the head of department himself. They are approachable and very concerned about all aspects of my learning and development. This has made my learning so much easier as I feel so at home and comfortable in seeking advice and asking for help.
I am glad I returned, and we are all ready to welcome people with the same passion with open arms.
Dr Adrian Loh
Medical Officer (Trainee)
My posting in Consultation-Liaison Psychiatry, Department of Psychological Medicine, NUHS
As I write this in Oct 2009, I am coming to the end of a 6-month posting with the Consultation-Liaison (CL) team. During this posting, my understanding of mental health issues in the patient population of a general hospital has grown tremendously. Because NUH is a tertiary hospital with a very wide spectrum of disciplines under her roof, our CL team receives referrals for patients spanning the different stages of life, from diverse social backgrounds, with eventual diagnoses that may be "common" - such as depression - but with presentations that are unique due to the interaction with their admitting problems. On the other hand, I managed to encounter vary unusual cases - various neuropsychiatric manifestations of organic illness, unusual somatoform syndromes, come to mind - that kept my mind active with trying to figure out "the problem".
As a trainee, I appreciated the way the CL team is set up here in NUH. The concept of a multi-disciplinary team, comprising doctors with different levels of expertise, senior nursing practitioners and a psychologist, resonated with me as it allowed me to understand their individual perspectives. A weekly discussion of cases, the "Board Round", is the forum where trying to figure out "the problem" takes place as a group - I never found groupthink to be a problem here, as we each had the opportunity to propose possible differentials. This system "forced" me into a habit of formulating cases holistically and enabled me to consolidate my grasp of the diagnostic criteria across a wide range of conditions.
The liaison aspect of CL work, which most acknowledge to be harder to achieve than the consultation aspect, is an area which I had some opportunity to practice. Because I was a member of the CL team for the duration of my posting, I became quite familiar with some of the ward medical and nursing staff, and had the opportunity to provide some education on an informal basis.
Outside of CL itself, I benefited much from the training provided by the department. The training schedule is rather busy, but nearly all of the sessions I attended were relevant and pitched at an appropriate level. In addition to weekly case presentations and journal club sessions, there were 2 weekly tutorials conducted by the department's visiting consultants - 1 in general psychiatry and 1 in child and adolescent psychiatry. As a trainee, I am well aware that modern trends in psychiatry can emphasize the biological aspect of mental illness over the psychological and social aspects. Hence, I found it very valuable to attend the weekly psychotherapy interest group that brings together psychiatrists, psychologists, therapists and counsellors to discuss psychological work with featured patients. Finally, my personal supervisor was very helpful whenever we met weekly, facilitating discussions of interesting topics or trial OSCE stations.
Although not a large department, Psychological Medicine in NUHS has psychiatrists representing most subspecialty interests - general adult, CL, child and adolescent, women's mental health, psychogeriatrics, addiction medicine, psychopharmacology, research, etc. I found that this broad mix allowed me ready access to subject matter experts when I had questions; at a departmental level, this enables both depth and breadth of discussion when cases are presented.
CL Psychiatry is not a posting to come to if a trainee is looking for an "easy posting". However, it is a rewarding posting, in a department that emphasizes thorough training, and this would help prepare you in your journey to be a psychiatrist.