My third rotation was psychiatry at Queens Hospital Center (QHC). In this rotation, I worked several days a week during the day shift in the Comprehensive Psychiatric Emergency Program (CPEP). I was nervous to start this rotation, as I have never worked with psychiatric patients outside of the regular emergency room. I would arrive to CPEP with my colleagues who were also on this rotation with me and I would start my day by going through the census. This consisted of going onto Epic and reading each patient’s story (the HPI from the previous provider), to understand what brought them in, how they were initially in CPEP, and to read any collateral information that was obtained. QHC CPEP was great, as it is staffed by PAs and psychiatrists. It was wonderful to be surrounded by so many PAs, as this allowed for a clear understanding of what is expected of a PA in this field and their relationship with the psychiatrists.

This rotation was unlike any of my rotations thus far, as the history and physical were completely different from what I am used to. I learned the importance of asking certain questions to the patient, from the simple “how are you feeling today?” to questions in regard to their sleep and appetite or what plans they have when they are discharged from the hospital. Additionally, asking the patient if they have suicidal or homicidal ideations aids in understanding if they are a harm to themselves or others. This aided in my understanding of the disposition of the patient, as a patient who shows they are future or goal-oriented, who previously presented with suicidal ideations, is less of a risk as they show they have goals and things they are looking forward to. Obtaining collateral information is not typically a part of any history in another specialty, but in psychiatry and CPEP it is extremely vital. At first I was very nervous to call and collect information from the collateral, but I realized these individuals are willing to talk and want to talk in order to give the patient the best care possible. While collateral information often came from family that lives or sees the patient frequently, I also saw it comes from friends, case managers and psychiatrists as well. If there is one piece of information I will take away from this rotation, it is the absolute necessity of collateral, as many of these patients are acutely psychotic or will not provide the full or true story of what happened. Additionally, over the four weeks I became more comfortable writing the HPI for a psychiatric patient as there are certain aspects that need to be included in the first sentence such as who they are domiciled with and who activated EMS or NYPD. Lastly, I became more familiar with the mental status exam during my rotation. While I am still not completely comfortable with it, I was able to become more aware of certain affects or thought processes when assessing a patient.

While this rotation certainly provided many memorable moments and patients, there are a few stories that will remain with me. One patient was a young female adult, who had multiple somatic complaints for many months, who was cleared by multiple emergency departments and specialists. She stabbed herself in the neck because she was unhappy with how her parents were responding to her complaints and because she could not handle all of the pains and symptoms she was having. It was certainly interesting to see a patient who firmly believed she had all of these symptoms and that there was something very wrong, despite evidence of the contrary. Another memorable patient was this older gentleman who had nihilistic delusions, believing that the Earth was going to collapse and that everyone needed to evacuate. He would go to JFK to try to get on an airplane to escape or would wait at the beach for a ship to bring him to safety. I had the pleasure of speaking to the patient’s wife over the phone to collect collateral and it was difficult to listen to this patient’s wife state that a previous hospital did not listen to her when she repeatedly told them he has a past psychiatric history of schizophrenia years ago and that she firmly did not believe he had dementia. One of the most difficult parts of this rotation for me was listening to the collateral speak about the struggles of not only the patient, but what they as the caregiver or significant other has had to deal with, and how they want and need help for these patients.

It was certainly challenging to interview patients that did not want to cooperate or provide any information. This made it extremely difficult to learn why the patient arrived in CPEP, how they are feeling or who could be contacted. When a patient does not want to respond, it is definitely a skill to be able to redirect the patient and get them to answer any type of question, regardless if it is related or pertinent to why they were in CPEP to begin with. Since patients with psychiatric illnesses are not exclusive to my psychiatry rotation, I plan to continue to work on my interviewing skills by changing the subject or approaching the patient with another question in an attempt to have them open up and feel more comfortable speaking with me. I think many of these patients just want a provider to listen to them and providing that space and time for them is something I plan to continue to offer going forward. I want my preceptor, the PAs and psychiatrists to know that while I often felt anxious in CPEP, I worked my hardest to ask the patients questions while we were interviewing them, and never hesitated to collect collateral information. Going forward, I hope to use the interviewing and listening skills I learned on my psychiatry rotation and apply it to patients in my upcoming rotations.