My life as a ST4 in Old Age Psychiatry

In this instalment of My life as a doctor, we’re investigating what it’s like to be in old age psychiatry!

What stage of your training are you in?

I am training in old age psychiatry (higher specialty training), and I’m at ST4. In addition, I am an NIHR Academic Clinical Fellow, with ST4 being my 3rd and final year.


Where are you working?

In the East  Midlands, the North.


When did you choose your specialty? What else were you considering?

In the second year of medical school I was drawn to the psychology-based lectures we received. I intercalated in psychology and then did a masters in war and psychiatry.

I purposefully chose a foundation programme carousel that had psychiatry – it was all going to plan. I really enjoyed my foundation programme jobs in critical care and renal medicine, and for a time I considered ‘jumping ship’ to core medicine. In the end I stuck with core psychiatry training and haven’t looked back.

The opportunity arose on CT2 entry to convert to an academic clinical fellow – which was a good outcome as the protected time and extra support to hone my research skills is a welcome break from clinical practice (and recharges me)!


What brought you to your decision / Any deciding factors?

For me, psychiatry is fascinating because the basis of practice is a phenomenological one. We rely on what we observe and what our patients report to us. In addition, we do not understand the physiology of consciousness yet, but I firmly believe that this is something we will understand in my life time – so why wouldn’t you want to practice in such a field?


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

I completed the exams earlier this year – a prerequisite for obtaining the MRCPsych and beginning higher training (there are no ‘exit’ exams). Overall they were fine, but I suspect that, like many other specialties, there are questions raised about their clinical relevance.

Paper A focuses on the scientific basis of psychiatry, covering topics such as pharmacology, neuroscience and psychology. Paper B is more clinically relevant and focuses on management, as well as statistics and clinical appraisal. The practical exam is the CASC, and like any practical exam it is all about practice. In psychiatry, perhaps more that others, advanced communication skills are key.

For the written papers I used the SPMM online question banks, notes and mock exams. For the practical I practiced with colleagues, used a book called “Get through the MRCPsych CASC” and watched the online SPMM videos which demonstrated stations.


How is your day job split up?

You have a lot of control in psychiatry higher training about what you do, and you’re encouraged to almost be ‘selfish’ in selecting the clinical experiences that you need. At present I do 2 days liaison psychiatry (in general adult and old age psychiatry, you can gain an ‘endorsement’ as a liaison psychiatrist when you CCT) and 2 days with a CMHT.

We’re also able to do a day a week as a ‘special interest’ and as long as your TPD is aware you can pretty much do whatever you want. I have chosen to do addictions psychiatry and at present am piloting an alcohol-related brain injury diagnostic service.


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

Liaison psychiatry and addictions have been particularly enjoyed. I plan on practicing as a liaison psychiatrist in the future, and clinical I feel I will be well placed given my experience with dementia and addictions.

The hardest bit is obtaining your psychotherapy competencies. The time is tight to meet the requirements in core psychiatry training, and there are increasing expectations in higher training. The supervisors are all excellent, but it can be difficult identifying the right patients. There are also not that many supervisors (medical psychotherapists), so your options can be really limited.


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

It’s never boring, and colleagues from other specialties would never describe psychiatry as boring, though it can be considered a ‘marmite’ specialty. Furthermore, the role of the psychiatrist is a varied one, encompassing clinical excellence, psychological expertise, as well as management and leadership. For me, it’s all the best bits about being a doctor.

However, core psychiatry training can be somewhat same-y, especially when you’re considering the on-calls. These become far more ‘psychiatric’ when you’re a higher trainee. As mentioned earlier, obtaining your psychotherapy competencies in the available time can be challenging.


Could you share with us your most challenging moments?

In my psychiatry training so far, the most difficult decision I had to make pertained to the academic side of my training. There is an expectation that academic clinical fellows secure funding for a PhD training fellowship, and then go out of programme for a few years.

Whilst I really enjoyed the academic side of my training, I came to the realisation that the PhD route, and subsequent post-doctoral research, was not something I wanted to do.

First and foremost I see myself as a clinician, and a better one now given my academic experiences. I think would struggle reversing this, which appears to be what is required in the ‘true’ clinical academic training pathway.


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

You need to have an interest in the experience of others. The diagnosis is pretty irrelevant as, for example, two people with borderline personality disorder are two very different people with varied experiences. If you’re able to take the time to understand the person then you can do a lot of good. Distilling experience down to ‘diagnosis and treatment’ will only get you so far in psychiatry.


Can you tell us about any interesting breaks or side projects you have undertaken during your training?

In my foundation years I realised that my skillset pertained to leadership and management. Because of this I got involved with the Faculty of Medical Leadership and Management and learned about their National Medical Director’s Clinical Fellow Scheme. This is an annual competitive application process which places junior doctors with healthcare bodies to develop their leadership and management skills. I was lucky to be accepted onto the 2015/16 intake after completing my core psychiatry CT1 year.

During this year I worked at the NHS Trust Development Authority (later NHS Improvement), with the bulk of my work being on the 7 day hospital services programme, as well as SAS doctor medical engagement. This year was invaluable, I developed new skills and a wider perspective on healthcare in England. The skills I gained during this year are why I was successfully appointed as an NIHR academic clinical fellow, and later how I have been able to set up new pathways in my current role (an alcohol-related brain injury diagnostic service).


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

As with all specialty applications, to be successful you want to look at the publicly available person specifications and ‘sell yourself’ with them in mind. If you know psychiatry is for you from an early stage, then the foundation years provide a good time to pack out your CV with relevant things.

But I think the main thing to consider is whether or not you see yourself as a psychiatrist in the future. Are you interested in the experience of others? Do you feel that psychological therapies are key to keeping people well for longer? Are you enthused by the relative unknown of the human mind’s physiology? These are just some questions to ask yourself, which hopefully tell you whether or not this is the specialty for you.


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