On many rotations or sites you will be required to wear your white coats, although on others you may not be required to do so. In any event, you are expected to dress as a professional, which includes collared shirts and ties for men, appropriate dresses or slacks for women, and no shorts in either case. In addition, both men and women are reminded that sexually provocative clothing (e.g., open shirts for men or low cut dresses/blouses or high hemlines for women) is inappropriate when working with psychiatric patients.
Contrary to common belief, most psychiatric patients present no physical danger to others; however, some patients may pose such a risk. WE DO NOT WANT ANYONE - STUDENT, RESIDENT, FACULTY, STAFF, OR PATIENT - TO BE INJURED; thus, it is important that you follow all safety instructions from rotation or site personnel and that you always be cognizant of safety considerations. Because psychiatric patients may not think clearly or behave normally, alterations of your usual behavior with others may be required. Furthermore, such patients may be sensitive or disturbed by statements or behaviors on your part that would otherwise be innocuous. For all of these reasons, please remember that when a faculty member, psychiatric resident, or site staff member asks you to stop talking about or with a patient, leave the room, or gives you other specific directions, you need to do so immediately and without question. Thereafter, you should feel free to ask for an explanation of any directions, which you did not understand.
There is another important point to be made with respect to physical safety and violence. If a patient should become violent, it is not your task, as a medical student, to intervene. Indeed, it is best that the job of containing a violent patient be left to those who know how to do it: the staff and Public Safety. If you try to intervene without appropriate training or skills, it increases the likelihood that you, the patient, or someone else will be injured.
Mental health professionals have special, specific, and very stringent professional and often legal obligations, with respect to certain behaviors with mentally ill patients. The concept of "undue familiarity" refers to a mental health professional's obligation to avoid any sexual activity with his or her patient, no matter how the patient behaves (e.g., no matter how sexually seductive the patient may be). Similarly, any activity that might be considered a prelude to sexual activity or other "boundary violations" is proscribed. Indeed, numerous studies have demonstrated that the typical path to "undue familiarity" is not through the intentional plan of having sex with patients but rather by means of a "slippery slope" in which initial, small, and seemingly innocent "boundary violations" lead to greater and greater violations. Thus, as a physician in general, and in psychiatry in particular, you will need to be careful not to move from a professional relationship to a friendship with your patients while, at the same time, remaining human, kind, compassionate, caring, and polite. As a helpful reminder, always carefully consider apparently "benign" requests on the part of patients that may compromise your professional relationship with them (e.g., no matter what the reason, one should be wary of agreeing to meet a patient in a restaurant in the evening). If you are unsure as to whether certain activity with a patient is within appropriate professional boundaries, then be sure to ask your supervisors.
Please note: a student who engages in any sort of sexual activity with a patient, "dates" a patient, or otherwise inappropriately fraternizes with a patient outside of the clinical confines of his/her rotation or site will be immediately dismissed from the clerkship, will automatically be given a failing grade for the clerkship, and will find himself or herself before the Student Promotions Committee.
Mental health professionals also have special, specific, and often very stringent professional, and often legal, obligations with respect to issues surrounding patient confidentiality. Please remember that psychiatric diagnoses are typically more "dangerous" and destructive to a patient's work and reputation than are "medical" diagnoses. You can easily imagine that suffering from congestive heart failure or diabetes carries nowhere near the stigma of being labeled a "schizophrenic" or "manic-depressive." Furthermore, psychiatric patients often reveal intimate secrets about themselves or their families, information, which could be very destructive if it were to come into the wrong hands. While all physicians have to pay great attention to issues of confidentiality, this is especially so in psychiatry.
Thus, while we recognize that you will often discuss your experiences on this clerkship (just like other clerkships) with friends, spouses, and families, we expect you to take extraordinary care in doing so with psychiatric patients. Patient names should never be discussed and specific details that may inadvertently identify a patient and/or his circumstances should not be revealed to anyone without specific authorization by your faculty clinical supervisor. Furthermore, you are not free to speak with family members, employers, or friends of patients (in person or on the phone) without the explicit permission of the patient. While there are some exceptions to these rules, such as situations in which the physical safety of a patient or others may be seriously and imminently threatened, the safest course is to be very careful in speaking about a patient with others. Again, when in doubt, please check with your supervising resident or faculty member.
The above notwithstanding, should you learn from a patient or others, in the course of your work, that a particular patient is suicidal, homicidal, or otherwise at risk for physical harm to self or others, you should immediately inform your Attending Psychiatrist, your resident, or appropriate staff members on site. Similarly, any serious concerns you have about a patient should be so communicated. Remember that you are a part of a treatment team, and within such teams it is expected that all relevant and important information will be communicated to other team members.
The mentally ill are just like you and me. All of us know someone (family member, friend, classmate) who suffers from a psychiatric disorder, and most of us have had our own personal experience dealing with depression, anxiety, substance abuse, and/or other mental illnesses. The mentally ill are suffering people; they are not "crazies" or "loonies" that are fundamentally different from those of us currently enjoying better mental health. Thus, we expect you to treat psychiatric patients as you would want to be treated yourself if you were in a similar situation - with respect, empathy, and compassion. The Golden Rule is just as valid in psychiatry as it is in other aspects of life. Insensitive, hurtful, thoughtless, demeaning, or stigmatizing comments will not be tolerated. And, in this respect, another important reminder (again relevant for psychiatry but also other medical and surgical rotations): patients often hear conversations that take place in nursing stations; please be careful what you say there.
