My all-time favorite comment from a student evaluation would have to be: “this rotation did not scar me for life.” This particular student found themselves on my inpatient acute psychiatry rotation as their final Advance Pharmacy Practice Experience (APPE) rotation, randomly assigned to them by their college of pharmacy. This student had no particular interest in psychiatric pharmacy and admitted to feeling nervous due to “horror stories” they had heard from classmates who had completed similar rotations at the state mental hospital and their perception of serious mental illness (SMI) from the media. This is a scenario I oftenfind myself in as an APPE preceptor for an inpatient acute psychiatric pharmacy rotation. Unlike my PGY1 and PGY2 residents who choose psychiatric pharmacy rotations because they have an interest in addressing mental health, most of my APPE students end up with my rotation because it was the only elective available. Helping these students feel comfortable interacting with patients with SMI and engage in the rotation offers its own unique set of challenges as a preceptor.
This is likely not the student’s first interaction with a patient with SMI, whether they know it or not. One in twenty U.S. adults live with serious mental illness.1,2 Patient’s with SMI are at a higher risk of comorbid medical conditions such as cardiovascular disease, diabetes mellitus, respiratory disease, stroke, pneumonia, pain, and hepatitis C compared to the general population.3 Students interact with SMI patients during their community, ambulatory care, and general medicine rotations. Regardless of the area of pharmacy they choose to practice in, they will continue to have interactions with patients with SMI throughout their careers.
Students will see impulsive, agitated, aggressive, and sexually inappropriate behavior by patients on the unit. During orientation we discuss what types of behaviors they are likely to see and why they are seeing them. Most health care professionals who have worked on an acute psychiatric unit have received some form of training in disruptive behavior management and de-escalation. While it is not always practical to provide the same level of training to APPE trainees, consider making the first topic discussion about identifying and managing patients’ agitation and aggression and maintaining basic personal safety on the unit. The Agitation and Aggression in Practice Toolkit provided by AAPP is a great place to start. Finally, let the student know exactly how you expect them to respond to these situations when they occur.
I am blessed with a truly amazing and supportive treatment team who are as committed to clinical trainee education as I am and I utilize their services as much as I can. Introduce your student to the nursing staff, psychiatrists, nurse practitioners, social workers, recreation therapists, even environmental service staff. Schedule in time for your student to shadow or interact with other members of the treatment team. Let them know exactly who they can go to for help and who is watching out for them even if you, the preceptor, is not in the immediate vicinity. I found that pairing a student with a pharmacy resident or other health care trainees is another great way to help them feel less alone on the unit.
The most important thing I want a pharmacy student to take away from my rotation is to feel as comfortable discussing mental health medications with an SMI patient as if they are discussing insulin with a patient with diabetes. Yes, we will spend time on treatment guidelines, landmark studies, medication dosing, and monitoring but the majority of the time is focused on patient interactions. Don’t let them get stuck in the chart review. Not only should you schedule your students to round with the treatment team, lead patient educations groups, provide individual counseling, but also encourage them to participate in non-pharmacy recreation groups, play dominoes, or join an art session.
Taking time at the beginning of the rotation to get to know the student’s personal goals and motivations for the rotation as well as their initial perception of SMI can go a long way towards finding ways to engage students on an acute psychiatric pharmacy rotation.