Now that I have finished both a psychiatry core rotation at the Royal Blackburn Hospital in the UK as well as a psychiatry sub-internship elective rotation at Mt. Sinai Hospital in Miami, I’ve come to understand the main similarities and differences between the practice of psychiatry in these two locations. While the diagnoses and treatments are more or less the same in both the US and UK, the approach can be quite different. Nevertheless, in both countries, I have had really good learning experiences, and absolutely love and look up to the doctors I rotated with, who are all professional and passionate about what they do.
Disclaimer: I can only speak about my experiences at these two hospitals, Mt. Sinai Hospital in Miami and Royal Blackburn Hospital in Blackburn, England. There may be wide differences in the approach to healthcare among different hospitals within the US as well as the UK, which I cannot address here. I also cannot speak for which system is “better,” but only what I can learn about patient care as a student from these two systems.
In Blackburn (UK), the doctors dedicate about 30 minutes to an hour seeing each patient during ward rounds, and they see each patient once or twice a week, 4 patients per day. The encounters take place in an interview room, and each patient is scheduled to see the doctor one at a time. During the ward rounds, the doctor, social worker, nurse, secretary, (and the medical student), and any other professionals involved in the care of the patient are present in the room. Before the patient comes in, everyone in the room usually has a discussion, getting updates about the patient to make sure everyone is on the same page with the patient’s care. Then, the patient comes in and the interaction is usually between the doctor and the patient (and/or the patients’ guardian or caregiver). After the patient leaves, the doctors, nurses, and social workers have another discussion over the encounter that just took place and discuss the next step in the plan. The entire encounter may take up to an hour for each patient.
Because of this scheduling in Blackburn, I saw the doctors conduct very thorough interviews with the patients during the ward rounds and as a student, I learned a lot about the patients’ lives as well as how to do very thorough psych interviews. It was also really good to see how doctors, nurses, and social workers work together as a team to provide care for a patient. Because each doctor only sees about 4 patients per day, I also found that the doctors had more time for students and are very willing to teach students one-on-one. It was not uncommon for my attendings in the UK to sit down with me and teach me about risk assessment or psychosis for an hour or two. I feel that I learned the fundamentals well because of these one-on-one teachings I got from the UK.
On the other side of the world, here in Miami, the approach to psychiatry is much different. Here, the doctors see patients for only a few minutes each day during ward rounds, and usually without social workers or other members of the care team present. But despite the short contact with the patients, the patients are seen nearly everyday by the doctor. On an average day, the psychiatrist here in Miami sees about 20-30 patients per day, but only spent about 2-3 minutes with each patient. Rather than having the patient scheduled to come into an interview room at the ward of the hospital to see the doctor and the care team (like it is in the UK), the doctor-patient encounters in Miami are not scheduled. Rather, the doctors here go into the patient rooms to see the patient, who are often in bed or sleeping, and often with the TV on. Most of the patients here also have a roommate (whereas in Blackburn, every patient has a single room). I found it often difficult to assess the appearance and mood of the patient in this setting as the patient was often drowsy from just being woken up by the doctor or distracted with a TV or roommate in the room, and not in the patient’s regular state of mind. I find the patient encounters in the UK much more orderly and controlled when compared with my experiences here in the US.
As I mentioned before, here in Miami, there’s usually about 20-30 patients to see per day. Because there are so many patients to see in a day, students here in the US often contribute more directly with the patients’ care by helping out the doctor in seeing patients during ward rounds and writing patient progress notes (under the doctor’s supervision). Often here in Miami, I was assigned patients to see and evaluate by myself, present my findings to the doctor, and fill out the daily progress note for the patient, which the doctor would review over, edit if necessary, give me feedback, and sign. It was a good experience because I often felt more like a doctor than a student. In contrast in the UK, all my interactions with psych patients were purely for practice and happened after the ward rounds were finished (this is for Psych only — the other rotations at Blackburn you do participate in the patients care more directly). So after 6 weeks in the UK and 4 weeks in the US for psychiatry, I’d say that I had a good student-learning experience in the UK but a good student-work experience in the US.
One of the differences that struck me are the services that the patients are provided. In Blackburn, once a patient is emotionally safe and stable enough, they may be granted temporary leave from the hospital to visit family, to get a smoke break, to take a walk or get some fresh air, or for any other various reasons. The leaves may be escorted or unescorted, and may range from a few minutes to a few days, depending on the patient’s progress and purpose. In the psych ward at Blackburn, there is also a patient gym with weights and treadmills which the patients may go to. The doctors at Blackburn often grant gym leave to schizophrenic patients who are experiencing weight gain from taking anti-psychotic drugs like olanzapine. Gym access helps them get active, improves their health, gives them something to do, and overall improves their psychiatric well-being. There is also a recreational facility at the psych ward in Blackburn called “Open Doors” which the patients may go to. At Open Doors, there is a pool table, ping pong table, couches, TV’s, and a kitchen where patients can cook food and get back into their normal daily lives. It’s a great place for patients to socialize with each other, contributing to the therapeutic environment of the psych ward. Having facilities like this also encourage the patient to want to improve, so that they may be granted permission to go to Open Doors. In addition, there is also a little convenience store at the psych ward where some patients can even help out at and get the work experience they need before going back out into the real world. I think all of these facilities and services at the psych ward in Blackburn make it a great place for patients to heal, improve, and get back on their feet. It gave me a view of the complex nature of psychiatric conditions, and the complex therapeutic interventions and services needed to help patients return to society.
In Miami, on the other hand, I do not recall seeing any patients granted leave from the hospital to visit family, or go to a hospital-based gym or recreation room (like Open Doors). I don’t think there was any. There are, however, smoke breaks 4 times a day, in which the patients are escorted to an area safe to do so, as well as group therapy led by social workers every day.
As I had mentioned in previous blog posts, the psychiatrists in the UK also do home visits. Home visits help reserve the psychiatric hospital beds for those who really need it, and not to mention, the home environment may be more therapeutic for some patients. Patients discharged from the hospital are also provided doctors, social workers, or other care coordinators to follow up on them at home every other day or so, to make sure they are adjusting well at home and are compliant with their medications, give them support, and to simply say hello. I found the home visits during my time in the UK to be very interesting because it gave me a glimpse into the home setting and social situation that the patient was coming from, and it’s a dimension of the patient that is not often seen from the hospital setting. It really let me understand the patients’ conditions and how an entire team works together to treat patients. It still amazes me today that all of these services are free in the UK. In the US, I don’t recall seeing any type of service like this.
So in conclusion, the med student experience in the US and the UK can be very different due to the different systems’ approaches to patient care. Over these past few months, I really appreciate the opportunity to have experienced psychiatry in both the US and the UK, and it gave me an insight on the strengths and weaknesses of the different systems. But whichever system we end up practicing in, the most important thing is to do what’s safest and most effective for our patients. And as students, whichever place one chooses to do clinical rotations, the most important thing to know is if you’re proactive and eager to learn and ask questions, you’ll learn no matter where you go. Best of luck everyone!