Service Rounds - Patient Centered Teaching Creates a Common Language

Each Friday for two hours almost every PGY2, half the PGY3s and several of the PGY4s meets together with either the department chair (Dr. DePaulo) or one of the other senior attendings (often Dr. Slavney) for service rounds. One resident brings a patient they have been caring for -- either an outpatient they are following or a current inpatient who is well enough to leave the floor for an hour or so. The resident takes 10-15 minutes to present the patient's history, exam and course of treatment. Then the attending interviews the patient for another 15-20 minutes. Each of the other residents then has the opportunity to ask the patient a question. Once the patient leaves, the attending leads a teaching session that is centered around understanding the psychiatric problem or problems facing the patient we all just saw together. This teaching session is conducted by asking each resident a question, or questions designed to bring key points into focus. The PGY2s are asked questions first and the questions increase in difficulty and complexity for the PGY3s and 4s.

Often the first questions asked focus on describing the patient’s current mental state and what we can learn from observing their appearance, speech, behavior and their own descriptions of their current state of mind. We then usually discuss formulation. What disease, life event or behavioral problem accounts for the trouble that brought the patient to a psychiatrist? How has their temperament and personality shaped the way they’ve responded to their circumstances and contributed to their current problems or protected them from worse trouble? Sometimes the discussion will turn to the history of our field or alternative ways of understanding the patient. How might Freud have explained the phenomena we’ve all just observed? How might someone who wants to account for all psychiatric phenomena in terms of abnormal brain activity explain the patient’s presentation? Which clinically relevant factors might this approach miss? Finally, we almost always discuss management. Why did the treatment team make the choices they did? What are other options for treating such patients? If this were your outpatient, how would their temperament and life story effect your approach to psychotherapy? We all listen and learn from the answers our colleagues give and the answers our attendings are looking for.

It isn’t a high-pressured atmosphere. We aren’t made to feel embarrassed for not knowing an answer or giving a different answer than the attending. Nonetheless, you want to be able to answer the questions asked and I certainly find that the questions and answers I remember best are those I get wrong.

Service rounds is probably the most important structured didactic of our residency. Its quite grounding to see the same patient together with the rest of the residents and with one of our most experienced teachers. The fact that we are all able to examine the same patient at the same time helps ensure that we come away from residency using the same terms to describe the same phenomena. That our teachers force themselves to structure their didactics around the actual experiences of patients (along with relevant research that is frequently referred to during these sessions) helps ensure that these actual experiences (along with data derived from similar patients) form the bedrock of our understanding of what it means to practice psychiatry.