In response to the article by Dr Gill Garden (Reference GardenGarden, 2005) on physical examination in psychiatric practice, I would like to highlight some of the problems that trainees in psychiatry frequently encounter.

I certainly applaud the Royal College of Psychiatrists’ increased awareness of physical illnesses and the importance of detecting them, but I fear that the level of teaching that juniors receive for this is extremely poor. Indeed, having come through a large SHO rotational scheme, I cannot recall a single lecture that was devoted to carrying out a physical examination and yet this is now an essential component of the OSCE in the MRCPsych Part I exam. Even in Part II, as many marks are set aside for the physical examination as for the mental state examination.

In a field such as rehabilitation psychiatry, patients’ physical problems are even more important because individuals are often on high doses of medication (possibly with polypharmacy) and are usually older and less physically active. Fortunately at St Michael's Hospital in Warwick, a local GP has two allocated sessions a week to deal with any physical problems on the rehabilitation wards, and this shared-care approach, similar to that described in APT by Reference LesterLester (2005), is valued by both patients and staff. It also ensures that long-term psychiatric patients receive adequate screening.

With new guidelines constantly being issued on the checks we should be performing on patients taking psychotropics and the ever-present threat of medicolegal implications, I feel it is time that more emphasis in our training be placed on physical examinations, with regular refresher courses – perhaps similar to advanced life-support courses – even after membership. This must also involve psychiatric nursing staff, who usually have only basic ‘physical’ training: perhaps the Royal Colleges of Nursing and Psychiatrists should jointly look into this. A combination of the shared-care approach by primary and secondary services and an increased emphasis on teaching psychiatrists and psychiatric nurses about physical illnesses is, in my opinion, the best way to look after the holistic well-being of our patients.

By the way, for those of you who always wanted to know how to calculate the QTc interval but were afraid to ask, I found this formula in Kumar & Clark's Clinical Medicine:

\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \[QTc\ =\ QT\ interval\ divided\ by\ the\ square\ root\ of\ the\ R-to-R\ interval\] \end{document}

Now you just have to know how to read an ECG!