NOTE:  COMPLETE COURSE INFORMATION IS FOUND ON THIS PAGE AFTER THE LINKS.  FOR SPECIFIC INFORMATION CHOOSE ONE OF THE FOLLOWING LINKS. 

  Welcome to your clerkship in Psychiatry

1. Mid-term Vignette
2. Quizzes
3. Final Exam/Final Vignette
4. NBME Psychiatry Subject Exam

Patient Write-ups and Case Presentations

Neurology Experience in Fargo

Neurology Experience in Bismarck

Additional Required Experiences in Bismarck

1. Prison Experience

Substance Abuse Treatment Program Experience (SATP)

1. Bismarck SATP Experience (Heartview)
2. Fargo SATP Experience (First Step Recovery)

Didactic Experience

Case Presentation and Teaching Class  

Evaluation Forms

Patient Data Record

Grades

1. Honors
2. An unsatisfactory grade
3. An incomplete grade  
4. Remediation of unsatisfactory grades

Holidays

General Plan and Goal of Psychiatry Clerkship

Specific Objectives

Welcome to Your Clerkship in Psychiatry.

We intend this to be a rigorous but fair experience for you which builds on what you have learned in your pre-clinical courses in the first two years of medical school. The primary textbook for this course is the same text used in the second year.  Click here for a list of required textbooks, optional books, and other recommended reading.       We also expect you to have available a copy of the DSM-IV. Copies may be available on the wards.   

Your preceptors might also recommend readings for your benefit based upon patient's encounters.  You will also be expected to do some limited research of the literature in preparation for a teaching experience you will provide for your fellow students.

We do not assume that you will know all of psychiatry by the conclusion of your clerkship, but we do anticipate that you will know basic psychiatric diagnostic and treatment considerations to a greater extent than expected of you in the second year. Your knowledge of such material will be assessed through your clinical work and in the following ways: 
 

1. Mid-term Vignette

A "mid-term" vignette discussion is scheduled for week 3 (see Schedule).   You will view videotaped patient interviews and discuss essay questions on the cases. A faculty member will share in this discussion with you and review your responses with you. This will help prepare you for the videotaped final vignette portion of the final exam. 

2. Quizzes

The vignette quizzes are paper cases with clinical scenarios and questions.  There will be three quizzes given over the course of the clerkship starting with the first quiz in week four.  The two best scores out of the three quizzes will contribute towards your final grade.

3. Final Exam (vignette essay questions)

A Final Exam will be given at the end of the clerkship--which must be passed at a 75% correct level. This exam will consist of essay questions based on videotapes of patient interviews. Failure to pass the final will require remediation via an oral exam or other appropriate re-testing.   Failure to pass the re-test will require a 4 week remediation experience in general psychiatry which will be graded pass/fail. 

4. NBME Psychiatry Subject Exam

You will take the NBME psychiatry subject exam at the end of the clerkship.  A raw score of 60 on this exam is considered passing.  Failure to pass will require a re-test.  Failure to pass the re-test will require a 4 week remediation experience in general psychiatry which will be graded pass/fail.

To help you prepare for these examinations, objectives on which you might be tested have been included on this website. 

Click here for objectives.

Preceptor Assignments

Every student is assigned to a preceptor for each component of  their rotation. The student makes the initial contact with the preceptor(s) or "named" person at the beginning of the clerkship. The preceptor will be responsible for the student's clinical experience. Students are responsible for meeting with their preceptors at least once a day.  Students will be expected to function with a degree of independence as outlined by their preceptor and to engage in self study related to conditions and treatments for patients they follow.

It is advised that at the beginning of the rotation, each student meet with his/her preceptor and discuss the goals and objectives of the rotation with the preceptor. This would include the hour expected of the student to be on duty, when the student is expected to be on call or rounds with the preceptor, the manner of patient contact and level of student involvement and responsibility in both the clinic and the hospital. Also, read through the evaluation forms to familiarize yourself with the skills and knowledge that will be assessed by your preceptor.   Students will be expected  periodically to seek feedback from their preceptors regarding their performance and to review with their preceptors the data in types of patients recorded in their pda.

If your preceptor works, you work. If your preceptor is off, you are off. It is the policy of the School of Medicine & Health Sciences that third and fourth year medical students be considered "professionals". Therefore, each student takes only holidays his/her preceptor takes, not holidays observed by the school. 

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Patient Write-ups and Case Presentations  

Four acceptable write-ups as evaluated by your various preceptors are considered a minimum for the clerkship.   (Refer to Psychiatric Write-up.)    "Acceptable" write-ups are to be turned in to the clerkship office and will be included in your clinical portfolio.  Actual patient names are to be thoroughly blacked out or pseudonyms should be used (please indicate that names are pseudonyms). A preceptor/mentor is free to ask for more patient write-ups as part of his/her teaching style.

Neurology Experience in Fargo

Students will spend two weeks at MeritCare Neuroscience seeing patients with a staff neurologist. This will occur during the 8-week psychiatry rotation. The students will be introduced to common neurologic problems encountered during a busy outpatient practice. During the rotation the students will rotate with each of the 5 teaching neurologists, thus maximizing the breadth of the experience.

In most instances the students will be observing how the staff neurologist interviews and examines the patients, and ultimately, formulates a differential diagnosis and treatment plan. Direct teaching will occur at the bedside and between patient visits. Each day will have a different topic.

With each topic will come a reading assignment and a summarizing didactic at the end of the day. The topics will include: the neurology exam and localization; demyelinating disease and CNS tumors; neurodegenerative conditions including Alzheimer’s and Parkinson’s disease; headache; cerebrovascular disease; seizures; back and neck pain including radiculopathies; pediatric neurology; CNS infections; and neuromuscular conditions.

Opportunities will be available to be introduced to electrophysiology studies such as electromyography, nerve conduction studies and electroencephalography.

At the end of the two weeks there will be a graded, 25 point multiple choice test.

Neurology Experience in Bismarck and Grand Forks

See above for topics and evaluation expectations.  On the Bismarck Campus students spend two weeks rotating with neurologists in an inpatient setting learning clinical exam skills and receiving topical didactic experience at the bedside.  In addition, students receive didactic presentations on a variety of topics from clinical faculty in neurology and neurosurgery.

Additional Required Experiences in Bismarck

Prison Experience

Each student is scheduled to accompany Dr. Samuelson to the prison once during the clerkship when there are no other scheduled activities for the students. Dr. Samuelson goes to the prison each week on Tuesdays from 9:00 a.m. to 12:00 p.m. Please contact him a few days in advance to confirm date and time. Students should meet Dr. Samuelson at the front desk of the prison at 9:00 a.m. He can only take one student at a time on these days but you are welcome to schedule a second visit to the prison with Dr. Samuelson if you so choose.  These dates are listed on your schedule.  

Please clear these dates with your scheduled preceptor.

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Substance Abuse Treatment Program Experience (SATP)

1 . Bismarck SATP Experience (Heartview)

The beginning process of the SATP Experience in Bismarck starts with an orientation session at Heartview with Marvis Doster, RN providing an overview of the treatment process along with a discussion and comments students have in relation to their own or others experience with substance abuse.  All students attend this as a group. 

The rest of the Heartview Experience is scheduled for each student on an individual basis.  Each student will be orientated to Heartview on a Thursday.  This includes meeting the counselors, the patients and their families, triage and assessment, detoxification, etc.  The following week the student will attend family programming from Monday through Wednesday sitting in on various group therapy sessions and review with the counselors.  The Heartview Experience ends on Thursday with a wrap-up session including a general discussion of the experience.  No dress code is required except for your name tag at this facility. Please read through the section in your orientation handbook entitled "Heartview" which lists goals, objectives, etc.

2. Fargo SATP Experience (First Step Recovery)

The Fargo experience is a two week rotation at First Step Recovery.  Michael Kaspari, R.N. and Director of First Step Recovery, will conduct an orientation to SATP on the first day of the clerkship. During your rotation, you will be involved in consultation skill building, group therapy, didactics on substance abuse and primary care screening. Skill building will focus on Recognition , Assessment , and Diagnosis of Substance Abusers. As you add to your knowledge and experience, incorporating psychiatric skills during the eight week rotation, it will be expected that you will move toward integrating these two areas in working with the Substance Abuse/Mental Health treatment team. 

We wish for this to be a learning experience, professionally and personally, as you interact with your own humanness and our patient population. We will support you in affirming those functions you do well and providing feedback in areas which need improvement.

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Didactic Experience

a.  Case Conferences 
b.  Case Presentation & Teaching Class
c.  General Conferences 
         Bismarck 
             Neurology Grand Rounds
             Family Practice Psychiatric Conference 
         Fargo 
             Grand Rounds 
d.  Orientation Lectures 
        Psychiatric Evaluation & Mental Status Exam 
        Psychopharmacology 

All didactic experiences are considered important learning and discussing times in your development.  As such they are mandatory and you will be expected to make up any missed experiences.  Check the clerkship WEB site for scheduled experiences.  If changes do occur you will receive e-mail notification.  Such changes will  also be reflected on the clerkship  WEB didactic schedule page.  You are responsible for checking this schedule. 

Case Presentation & Teaching Class

1.  Fargo Class Description & Expectations

During the course of your psychiatry rotation you will be given an opportunity to present a case to Dr. Carlson and your fellow students and to lead your colleagues in a discussion of that case. All students on the Fargo psychiatry rotation will meet weekly as a group on Wednesdays (see schedule). with each student being responsible for at least one presentation during the eight weeks.

You will have 90 minutes to accomplish the following:
1. Formal case presentation
2. Case discussion
3. Teaching the class

The case presented can involve any patient of your choosing with whom you have interacted during the rotation. You can ask your preceptor for ideas about this choice if you want. Usually students select a case that has been particularly interesting to them or that has presented some challenge in diagnosis or treatment. You may select a case because you feel it has been helpful in learning about a disorder or lead you to do extra reading that was useful. Your presentation should include the categories contained in the "write-up" format. Students have found it useful to refrain from giving their diagnostic impressions regarding the case and inviting their colleagues to begin a dialogue concerning the appropriate differential to consider. You will be expected, however, to have your own differential in mind. You are to turn in a copy of a formal case write-up to Dr. Carlson.

You should utilize all five axes, i.e., axis I -- V in reporting your diagnostic impressions. Please respect the confidentiality of your patients and either do not use actual names in the write-up and presentation or make sure that you eliminate names from the write-up.

The teaching opportunity is to be utilized to share with your colleagues some aspect of the case presented that you have researched and organized for teaching purposes. You should do a mini-literature search and find at least two appropriate and recent journal articles that apply to the topic on which you will be teaching. You can organize this in any way you feel most appropriate for helping your colleagues learn something new or in more depth. Handouts are always helpful, though you are free to become as creative as you desire. You will be required to turn in copies of the articles you researched to Dr. Carlson.

It is hoped that this experience will give you an opportunity to pursue a case in more depth, to learn how to do an organized psychiatric case presentation, and to gain some practice in leading a didactic session for colleagues. This will contribute towards your clinical protfolio grade. This generally turns out to be a very helpful and fun experience. Discussion is encouraged and expected from everyone involved.

2.  Bismarck Class Description & Expectations

Dr. Samuelson's Case Presentation/Discussion Groups Will Be Organized As Follows:

• Each student will present to Dr. Samuelson and the others students, a patient representing the psychiatric disorder taken from the primary areas list below.
• The presentation should be organized in such a manner as to promote free discussion and all students will be expected to participate actively. They will be expected to interview, observe, and interact with the patient that is present. (Ideally, the patient should be present for the student to conduct an interview.)
• Discussion of the case/patient will follow the presentation and interview of the patient with emphasis on the differential diagnosis and mental status exam. During the course of the case presentation, there will be open discussion to share with the students their own clinical experiences relating to the case topic.
• Each student will present at least once (sometimes twice) during the rotation. The order is determined by the students. It is the students responsibility to arrange these meetings each week and inform Dr. Samuelson which hospital they will be held at. He is dependent upon where the patient is at.
• Additional reading or literature searches on the topic to be discussed are encouraged as time can be used at the end of the presentation to "teach" fellow students about a particular objective or aspect of the patient syndrome.
• Students are required to turn in copies of their write-up for the patients they presented.
 

Primary Areas/Types of disorders students would likely encounter during their rotation:

- Social Phobias (Anxiety States, Panic Disorders, Generalized Anxiety States)

- Affective Disorders (Mania, Depressive Disorders, Bipolar Disorders)

- Schizophrenia and the other Psychotic Disorders

- Personality Disorders/Somatoform Disorders

- Geriatric Psychiatry (Delirium, Dementia, Cognitive Impairment)

- Psychiatric Disorders of Childhood and Adolescence (ADHD in children)

- Substance Abuse

- Mood Disorders

- Eating Disorders

The Students Should Be Prepared To Discuss:

- The etiology of the illness

- Symptomatology of the syndrome under discussion

- Treatment strategies including psychobiological and psychosocial

- Longterm prognosis

When Considered Appropriate: the following people can be included in the discussions to promote a multidisciplinary dimension.

Members of the treatment team:

- Psychologists/Social Workers

- Occupational therapists

- Pharmacists/Nurses

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Evaluation Forms

Evaluation forms are to be completed on-line for each of the preceptors and residents with whom you work throughout the clerkship.  The link is https://survey.med.nodak.edu/ome/Clerk/preceptor_eval.asp.You will also fill out an overall evaluation of the clerkship at the end of your 8-week rotation.  This can be found at https://survey.med.nodak.edu/ome/Clerk/clerkship_eval.asp. 

Your preceptors will fill out student evaluations.  To become familiar with the skills that will be assessed, go to https://survey.med.nodak.edu/ome/Clerk/stuassesspsyc.asp. The rating scale for the assessment of student performance corresponds to the following percentages:
.40 Does not meet expectations
.75 Minimally meets expectations
.84 Proficient/Competent
.92 Advanced
1.00 Exceptional
N/A Not observed or applicable


Patient Data Record

Use PDA.

Grades

You final grade will be obtained from seven sources: 

1.  Your Clinical Performance (30%):  This grade will be calculated based upon data in your clinical portfolio.  This data will include preceptors and other evaluators, write-ups, case presentation,  teaching materials, and didactic participation. 

2.  Your Clinical Vignette Exam #1 (5%).

3.  Your Clinical Vignette Exam #2 (5%).

4.  Your Final Vignette Exam (10%).

5.  Your NBME Exam (30%):  You will be awarded a 75% grade for passing the NBME Psychiatry Subject Exam.

6.  Your Neurology Experience (20%).

Refer to the Final Grade sheet for breakdown of percentages.

Honors will be awarded if all the following are met:

1. Recommendation by at least one of your clinical preceptors for a grade of honors along with the required examples provided on the evaluation form by that preceptor.  

2. A score of 90% or better on your clerkship clinical portfolio. 

3. A percentile rank of 70 or better on the NBME Psychiatry Subject Exam
   OR
   A score of 90 or better on the departmental exam.

4. Your final grade must fall in the top 20% of the combined class at the end of the year (this is a school-wide regulation).
    

An unsatisfactory grade will be awarded if any of the following occur:

1. You fail to receive a recommendation for satisfactory grade from any preceptor. 

2. Your final grade is less than 75 points. 

3. Your neurology score is less than 75%. 

4. You fail to score a 60 or above on the NBME Psychiatry Subject Exam. 

5. You fail to have satisfactory attendance at didactic sessions and conferences.

6. Your PDA entries are insufficient. You must log at least 2 patients per day on average. 

An unsatisfactory grade must be remediated, if possible, or the clerkship must be repeated.

An incomplete grade will be awarded if:

1. Recommendation from one of your preceptors, campus mentors, or campus supervisor for a grade of incomplete 
   or

2. Failure to complete tests or other requirements, including required write-ups and presentations.
   In both cases there must also be 
   - a statement from you approved by your preceptor, campus mentor, or campus supervisor and by the Clerkship Committee outlining how your grade of incomplete will be removed, and
   - approval of the Clerkship Committee after a review of reasons for this grade. 

Remediation of unsatisfactory grades:

1. If a student fails the neurology experience, make-up neurology experiences will need to be negotiated.   No more than 75% will be entered for students who pass on this basis.

2. If a student fails to receive a satisfactory on the NBME exam, another NBME exam will be administered with the same requirements for passing. If a student fails to achieve a satisfactory on the 2nd NBME exam then remediation will require a four-week clinical experience in a general psychiatry setting.  This will be graded as pass/fail. 

3. If a student fails to receive a satisfactory grade from a clinical preceptor or on their clinical portfolio, fails to obtain 75 points for the clerkship, or fails to have satisfactory attendance at didactic and conference sessions, or fails to attend required clinical rotation days, the clerkship will need to be repeated.

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Absence from Clerkship

With the exception of illness and personal emergencies, absence from the Psychiatry Clerkship is restricted to medical meetings. Permission to attend such a meeting must be obtained from your psychiatry preceptor and then requested from Dr. Carlson, Director of the Psychiatry Clerkship or Dr. Samuelson, Supervisor of the Psychiatry Clerkship for the Bismarck campus. 

If you are ill or have a medical emergency there are two phone calls you need to make. First, call your preceptor. Second, call Deb in Fargo at 701-293-4112 or Maxine in Bismarck at 701-328-9576. The campus office keeps track of any absences. 

Missed days from the clerkship will have to be made up unless otherwise negotiated with Dr.'s Carlson or Samuelson.

The only exception to this rule will be a meeting or activity which the administration (Dean) of the Medical School has given third year medical students permission to attend.

Holidays

It is the policy of the School of Medicine & Health Sciences that third and fourth year medical students be considered "professionals", therefore, each student takes only holidays his or her preceptor takes, not holidays observed by the University of North Dakota. 

General Plan and Goal of Psychiatry Clerkship

You will be assigned a preceptor for each of your clinical and SATP experiences. 

It is expected that students will complete their psychiatry clerkship in eight consecutive weeks. Students seeking exception to this rule must make their request in writing to Dr. David L. Carlson in Fargo citing the reasons for the request. Exceptions may be granted based on 1) amount of time away from clerkship, 2) the students performance up to the time of the leave, and 3) availability of a preceptor site similar to the one with which the student began. 

Students who complete the third year clerkship will be expected to have practiced all and become familiar with each of the following clinical skills and procedures:

1. Eliciting and clearly recording a complete psychiatric history utilizing the biopsychosocial case formulation. 

2. Eliciting, describing, and precisely recording the components of the mental status examination.

3. Using the DSM-IV to identify specific signs and symptoms that are the basis for diagnosis of psychiatric syndromes or disorders.

4. Demonstrating the following interview skills:

   • Initiation of interview.
   • Establishing rapport.
   • Use of open-ended & closed questions.
   • Use of summary statements.
   • Communicating information to patients clearly.
   • Appropriate closure of interview.
   • Techniques for asking "difficult" questions.
   • Use of facilitation, empathy, clarification, confrontation,
   • reassurance, silence.

5. Identifying clinical and demographic factors associated with increased risk of suicide.

6. Recognizing clinical findings that might suggest a general medical cause for symptoms such as hallucinations, delusions, confusion, altered consciousness, aggressive behavior, mood changes, anxiety.

7. Discussing the clinical features, differential diagnosis, and evaluation of delirium.

8. Screening for and obtaining (when necessary) a thorough history of a patient's  use of alcohol and other drugs of abuse.

9. Identifying typical presentations of abuse of alcohol and other drugs of abuse in general medical practice.

10. Discussing the process for obtaining an involuntary commitment and the physician's role in obtaining it.

11. Summarizing the elements of informed consent and determination of capacities (e.g. to consent to treatment, to manage funds).

12. Discussing the characteristics of, common indications and contraindications for, and how to make referrals for: psychodynamic psychotherapy, supportive psychotherapy, cognitive and behavioral therapies, group therapies, couples and family therapy, psychoeducational interventions.

13. Identifying indications, basic mechanisms of action & pharmacokinetics, common and serious side effects, signs of toxicity, and the guidelines for prescribing the basic classes of psychotropic medications.

14. Identifying indications, physiologic effects, side effects, and pre-treatment assessment requirements associated with electroconvulsive therapy (ECT).
    

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Specific Objectives for third year students in psychiatry include:

Clinical Problem Solving 

With regard to psychiatric and the substance abuse disorders, the student will be able to provide a deductive approach to diagnose most accurately the patient's chief complaint or presenting picture, including a list of the most likely, the most serious, the most treatable and the possible general medical explanations for the disorder. Also, the student will know indicators ("red flags") for the problems the patient may possess but which are not expressed as the presenting difficulty (e.g., alcoholism, "masked" depression, covert disease causing a behavioral syndrome). 

Knowledge Content

1. Diagnosis 

• Mood disorders and suicide risk factors

• Anxiety disorders

• Psychotic disorders

• Somatoform disorders

• Eating disorders

• Psychiatric syndromes caused by general medical conditions

• Alcoholism and other substance abuse disorders

• Cognitive disorders

2. Basic Psychopharmacology 

• Indications and counter indications for classes of medications

• Common and serious side effects and drug interactions for commonly used psychotropic medications

• Usual dosages and length of "adequate" trial

• Effects of age and medical conditions

3. Substance Abuse 

• Screening tools/techniques

• Behavioral, physical examination, and laboratory indications of overt and covert syndromes 

• Intoxication and withdrawal characteristics

• Detoxification regimen characteristics 

• Beneficial components of treatment methods, supportive social network,  treatment groups, and AA

4. Roles of Diagnostic and Treatment Team 

• Psychological testing 

• Neuropsychological testing

• Cognitive and behavioral techniques

• Substance abuse counselors

• Contributions of nursing staff, social workers, pharmacologists and other health professionals in data collection, treatment planning and treatment 

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Technical and Behavioral Skills 

The Student Will Increasingly Be Able To: 

1. Obtain information from patients in a manner that produces a minimum of discomfort for the patient, even topics of items that may be embarrassing or anxiety provoking.

2. Listen accurately to what the patient is saying.

3. Deal in tension-reducing manner with affectively-aroused patient.

4. Manage resistance presented by addicted persons and/or families including appropriately deployed confrontation.

5. Demonstrate knowledge of the rudiments of terminating the relationship with the patient.

6. Demonstrate the appropriate methods of managing medications and medication compliance.

7. Exhibit awareness of non-drug methods of treating patients. 

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Introduction to Clinical Neurology
     See handout from Division of Neurology.