What are the key areas of focus for a stage 3 training interview in psychiatry?

Key Areas of Focus for Stage 3 Psychiatry Training Interviews

Stage 3 psychiatry training interviews assess your ability to demonstrate advanced clinical competence across comprehensive psychiatric evaluation, risk assessment, treatment planning, and specialized population management, with emphasis on real-world clinical reasoning rather than theoretical knowledge alone. 1, 2

Core Clinical Assessment Competencies

Structured Diagnostic Interview Mastery

• Demonstrate systematic coverage of chief complaint, history of present illness, past psychiatric history, substance use history, medical history, family history, social history, and mental status examination 2
• Show proficiency in adapting interview techniques for different populations—simplify questions and allow extra processing time for patients with cognitive limitations 2
• Gather collateral information from knowledgeable informants across multiple settings to construct baseline functioning and identify symptom changes 2

Mental Status Examination Proficiency

• Assess general appearance and physical observations, speech characteristics, mood and affect, thought content and process, and perception and cognition 1
• Demonstrate ability to conduct developmentally appropriate assessments, considering developmental age rather than chronological age, particularly in child and adolescent cases 1

Risk Assessment and Safety Management

Suicide Risk Evaluation

• Conduct systematic evaluation of suicide risk with specific attention to actionable factors, not just screening questions 1
• Assess both active and passive suicidal ideation, with specific inquiry about past attempts and access to suicide methods 1
• Never dismiss suicidal thoughts as unimportant, and do not rely solely on symptom counts for assessment 1
• Document current suicidal or homicidal ideation, plans, or intent, and assess for any aggressive behaviors or thoughts 3

Acute Psychiatric Emergencies

• Know pharmacologic options for acute agitation, including benzodiazepines and antipsychotics, with understanding of their comparative efficacy and side effect profiles 2
• Demonstrate ability to attempt verbal de-escalation before proceeding to pharmacologic intervention 2
• Base psychiatric evaluation initiation on the patient's cognitive abilities rather than specific blood alcohol levels 2

Medical Clearance and Differential Diagnosis

Medical Stability Assessment

• Understand that "medical stability" is preferred terminology over "medical clearance"—determine whether medical conditions require acute treatment, not provide blanket clearance 2
• Obtain and interpret vital signs, as abnormal vitals may indicate underlying medical causes of psychiatric symptoms 2
• Perform targeted physical examination focusing on neurologic, cardiac, and respiratory systems rather than routine comprehensive exams 2
• Order focused medical assessment based on history and physical examination rather than routine laboratory testing 1
• Medical workup is indicated in cases of altered mental status, unexplained vital sign abnormalities, or new-onset or acute changes in psychiatric symptoms 1

Treatment Planning and Psychopharmacology

Medication Management Principles

• Match antidepressants to specific symptom profiles: sedating agents for insomnia and anxiety; activating agents for fatigue and psychomotor retardation 2
• Understand that most second-generation antidepressants have similar efficacy for moderate depression 2
• Assess therapeutic response and adverse effects within 1-2 weeks of starting therapy 2
• Evaluate target symptoms that were the focus of initial medication management, including any changes in severity, frequency, or impact on functioning 3

Shared Decision-Making

• Engage in shared decision-making by discussing treatment-related preferences, explaining differential diagnosis, and collaborating on treatment decisions 1
• Document rationale including specific factors influencing treatment choice, not just listing options 1

Assessment Tool Knowledge and Application

Screening Instruments

• Use PHQ-9 (cutoff ≥8) and PHQ-2 for initial depression screening, with full 9-item questionnaire if either item scores ≥2 1
• Apply cognitive assessment tools such as Mini-Cog (76% sensitivity, 89% specificity), MoCA, or SLUMS, with interpretation considering education level, language barriers, and cultural factors 1
• Do not interpret screening results without context 1

Standardized Rating Scales

• Use standardized rating scales to track symptom changes objectively 3
• Conduct comprehensive psychiatric review of systems including anxiety symptoms, panic attacks, sleep disturbances, and impulsivity 3

Special Populations Management

Child and Adolescent Psychiatry

• Implement medication trials using adequate dose and duration appropriate for the child's size and age 2
• Obtain informed consent/assent discussing benefits, risks, and alternatives with both patient and family 2
• Assess environmental and psychosocial factors including changes in routine, educational placement appropriateness, and stressors in patients with intellectual disabilities 2
• Never pathologize developmentally appropriate behavior 1

Family Assessment Competencies

• Understand family's cultural background, which directly affects views of normative family structure, communication style, belief systems, and child development 4
• Consider ancillary techniques such as family genograms (identifying facts and relationship patterns of three or more generations) and family timelines (mapping sequence of important events) for complex cases 4
• Assess how parent's internalization of family experience influences parenting, and how current interactional family experience affects the developing internalized psychological life of the child 4

Medication Safety and Side Effect Management

Comprehensive Medication Review

• Review current medication adherence patterns, including missed doses and reasons for non-adherence 3
• Document response to current medications, including degree of symptom improvement 3
• Always review the complete medication list, including over-the-counter medications and supplements, to identify potential drug-drug interactions 3
• Evaluate for any new drug-drug interactions with changes in medication regimen 3

Side Effect Assessment

• Systematically assess common side effects, as patients may not associate physical symptoms with psychiatric medications 3
• Assess medication side effects, particularly those common to psychiatric medications such as sleep disturbances, appetite changes, weight fluctuations, and sexual dysfunction 3

Psychosocial Assessment and Functional Status

Comprehensive Psychosocial Evaluation

• Assess changes in social, occupational, and educational functioning since the last visit 3
• Document impact of current symptoms and medication effects on quality of life 3
• Evaluate self-care abilities and need for additional support services 3
• Identify any new psychosocial stressors that may be affecting symptom presentation 3
• Document changes in social support, housing, or financial circumstances 3

Substance Use Monitoring

• Review current use of tobacco, alcohol, and other substances 3
• Document any changes in substance use patterns since the previous visit 3

Documentation Standards

Clinical Documentation Requirements

• Document "medically stable for psychiatric evaluation" rather than "medically cleared" 2
• Record thorough neurological examination findings 2
• Clearly document rationale for any laboratory or imaging studies ordered 2
• Note any new medical diagnoses, hospitalizations, or procedures since the last visit 3
• Document changes to non-psychiatric medications 3

Critical Pitfalls to Avoid

Common Assessment Errors

• Never allow patient-driven agenda to completely override systematic symptom assessment, as patients may be reluctant to reveal emotional problems due to stigma 3
• Do not assume stable psychiatric symptoms mean psychosocial assessment is unnecessary, as psychosocial factors predict healthcare utilization and relapse independent of symptom severity 3
• Never dismiss suicidal thoughts as unimportant 1
• Do not rely solely on symptom counts for assessment 1
• Avoid pathologizing developmentally appropriate behavior 1
• Do not interpret screening results without context 1

Training and Supervision Considerations

• Understand that knowledge acquisition is easier to demonstrate than skill acquisition, and these constructs do not always increase at the same rate nor positively correlate 4
• Recognize that reading treatment manuals and materials may be necessary but not sufficient for skill acquisition and adoption of psychosocial treatment 4
• Supervisors benefit from receiving specific instruction on how to supervise others in addition to instruction on treatment content 4