One important area of inadequate psychiatry oral board performance is on the treatment plan presentation. Here is the approach I recommend you take if you want to shine.
An optimal treatment plan should have the following three features.
1. It needs to be comprehensive
2. If needs to focus on resolution (or recovery) and not only response
3. It needs to be specific to the patient
To give this important area its due, I will cover each topic in turn. Today I tackle number 1.
1: Comprehensive Treatment Plans
This means that a treatment plan must address and seek to resolve every problem that is included on Axis I, Axis II, Axis III, and Axis IV.
Now, you are fully aware that as a mental health clinician you must deal with the problems on Axis I and II. But you may discount the need to address issues on Axis III since these are medical issues. But you do indeed need to identify and address them. Here is an example: Obesity. This is how I would phrase my intervention plan for this single issue.
“Problem: Obesity. This patient has gained 40 lbs since starting on olanzapine one year ago. These are the steps I will take to address this problem. One, I will begin weighing the patient, measuring his waist circumference, and measuring blood pressure at each monthly appoint. Two, I will order labs needed to assess for metabolic syndrome. That includes a fasting glucose, electrolytes, and a lipid profile. Three, I will engage the patient in a conversation encouraging a implementation of a regular exercise program. Four, I will refer to a dietician who will educate and aid the patient in developing healthier eating habits. And fifth, I will cross titrate the patient to a more weight-neutral atypical antipsychotic, such as aripiprazole.”
So you see, even something like obesity, a condition coded on Axis III, has an entire set of interventions that a psychiatrist should take.
Now, let’s move to Axis IV. Recall, that on Axis IV, we code “Psychosocial and Environmental Problems.” Now, if you’ve always filled out Axis IV but never really thought about why you were doing so, OR if you thought about it but didn’t really know why this needed to be done, now here’s your answer. You fill out Axis IV because it is your job to address and resolve every one of the problems on Axis IV.
Yes, I know that these are not psychiatric or medical problems. These are, nevertheless, problems your patient is facing and is unlikely to get better unless these problems are lessened. Here’s an sample presentation for “Financial Problem.”
“This patient has recently lost his job. He has already fallen behind on paying his gas bill for his home heating as well as on his mortgage payments. His gas has already been turned off and winter is approaching. So , number 1, I will have the patient work with a social worker who I will direct to complete a form for the gas company that allows restarting the gas even with non-payment when the non-payment is due to medical illness or other hardship. Two, I will have the social worker help the patient contact his mortgage owner in order to work out a payment plan to avoid the patient being foreclosed and ending up homeless. Three, I have concerns about this patient’s ability to obtain adequate food. On further interview I would focus on this issue. If I has remaining doubts, I would send out an occupational therapist or member of the Assertive Community Treatment team to evaluate the patient’s access to food. Concretely, I want to know what food the patient has in his house. There are food pantries that patient can be directed to obtain the food he needs….”
I could go on. My point is that every problem needs to be addressed and every problem, in turn, is likely to call for several appropriate interventions.
Last point on comprehensiveness. You have bio, and psycho, and social interventions available to you in your treatment armamentarium. (That’s why we call this a biopsychosocial treatment plan.) As you address each problem, consider the entire range of biopsychosocial tools at your disposal.
One of the few positive things I can say about the psychiatry oral boards in the US, is that your treatment plan need not be realistic. Many interventions may actually not be available in your area. But it doesn’t matter: present an ideal plan.
“Teach this triple truth to all: A generous heart, kind speech, and a life of service and compassion are the things which renew humanity.” The Buddha
Take care and …
Jack Krasuski, MD