PGIM MD Psychiatry common mistakes
PGIM MD Psychiatry · Understand the traps and how to avoid them.
In the long-case presentation, the candidate launches into a recitation of the referral letter and investigation results before establishing the patient's presenting complaint, chronology, and functional impact, so the examiner cannot follow the clinical reasoning.
Candidates rehearse the clerking template they used in undergraduate OSCEs and treat the viva as a data dump; under time pressure they prioritise completeness over a coherent narrative and never state a problem representation.
What to do instead
Practise a fixed opening: one sentence of problem representation ('a 42-year-old man with a three-month history of anhedonia and 8 kg weight loss, on two antipsychotics'), then chronological history, then risk, then formulation. Rehearse aloud with a timer and a peer instructed to interrupt if you present a test result before the symptom it was ordered for.
When asked 'what is your diagnosis and why', the candidate offers a single label with no differential and no explicit criterion-matching, and cannot say what would change their mind.
Trainees learn diagnoses as categories rather than as operational criteria applied to a specific history; they fear that listing alternatives looks indecisive, and they have rarely been asked to justify a diagnosis out loud.
What to do instead
For every major presentation rehearse a three-part answer: leading diagnosis with the criteria it meets and the features that are atypical, two or three realistic differentials with the discriminating features, and the investigations or longitudinal course that would revise the diagnosis. Use a structured diagnostic manual as a checklist, not as a label list.
The candidate discusses the patient's risk of self-harm only in vague terms ('low risk, no plans') without documenting the specific factors assessed, the protective factors, the formulation of risk, or a management plan with review.
Risk is often taught as a form to be completed rather than a clinical judgement to be argued; candidates fear that naming risk creates responsibility, and they have not practised articulating a risk formulation under questioning.
What to do instead
Prepare a standard spoken risk formulation covering static and dynamic factors, ideation, intent, plan, means, protective factors, and the resulting management and review interval. Practise stating it in under 90 seconds and then answering 'what would make you admit this patient?'
In the communication station, the candidate answers the patient's emotional cue with a further factual question or an immediate management plan, and the patient becomes more distressed or disengaged.
Candidates are anxious about covering the agenda and default to information-gathering; they have not been taught to recognise and respond to cues, and empathy statements feel artificial when unpractised.
What to do instead
Train a micro-skill sequence: notice the cue, name the emotion, pause, then negotiate the agenda. Rehearse with simulated patients and review recordings, counting how many cues you picked up versus missed. Build a small repertoire of phrases you can say without self-consciousness.
The candidate uses unexplained jargon with the patient or family ('we'll start an SSRI and titrate, your PHQ-9 was 18') and does not check understanding, then reports the consultation as shared decision-making.
Clinical vocabulary becomes automatic, and candidates equate giving information with obtaining consent; they rarely hear themselves from the patient's perspective.
What to do instead
Use a teach-back close ('can you tell me what you'll do if you miss a dose?') in every simulated consultation. Ask the simulated patient afterwards what they understood and what they were unsure about, and rewrite any phrase that required explanation.
When a relative or carer is present, the candidate takes history from the carer while addressing the patient in the third person, and does not negotiate confidentiality or the limits of what will be shared.
Carers often hold the most reliable chronology, so candidates drift towards them for efficiency; the legal and ethical framing of third-party information is under-rehearsed.
What to do instead
At the start, agree explicitly who is present, what the patient consents to share, and what will happen with information the carer gives. Address the patient directly, turn to the carer for corroboration only, and summarise back to both. Practise with a triad role-play including a carer who disagrees with the patient.
In the handover or multidisciplinary station, the candidate gives a chronological narrative of everything that happened rather than a structured summary with actions, ownership, and a time frame, and the receiving team cannot state what they are expected to do.
Handover is learnt informally on the ward by imitation, and trainees copy senior colleagues' unstructured style; they also conflate handover with case presentation.
What to do instead
Use a recognised handover structure (situation, background, assessment, recommendation) and always end with named actions, who owns them, and when they will be reviewed. Ask the receiver to read back the actions. Rehearse a 60-second handover of a deteriorating inpatient and get feedback on whether the plan was unambiguous.
In a conflict or disagreement station, the candidate either capitulates to a more senior colleague's unsafe plan or becomes adversarial, and does not use a graded assertiveness framework.
Medical hierarchy makes challenge feel risky, and trainees lack a rehearsed script for escalating concern without personal confrontation; they also have not practised separating the clinical issue from the relationship.
What to do instead
Learn and rehearse a graded assertiveness tool, moving from a clarifying question to stating the concern, to naming the risk, to invoking a formal escalation. Practise with a simulated consultant who initially dismisses you, and debrief on whether you reached a clear shared plan.
When asked to prioritise a ward or clinic list under time pressure, the candidate orders tasks by arrival or by who asked most recently, and does not articulate the clinical risk basis for the order or what will be delegated.
Day-to-day work rewards responsiveness to the loudest request, and candidates have rarely had to defend a prioritisation decision explicitly; they also under-use delegation because they have not practised it.
What to do instead
Rehearse prioritisation with a written list of ten competing tasks and justify the order by clinical urgency, time-critical windows, and risk of deterioration. Always state what you will delegate, to whom, and what you will do yourself, and identify what can safely wait until tomorrow.
The candidate cannot describe how they would appraise a paper or apply a guideline to the patient in front of them, offering only a summary of the study's conclusion without considering design, bias, or applicability.
Critical appraisal is often taught as a theoretical exercise detached from clinical decisions, and candidates memorise levels of evidence rather than applying them; journal club experience may be passive.
What to do instead
For each major topic, prepare one landmark trial or guideline and rehearse a two-minute appraisal: question, design, main result with effect size and confidence interval, main limitation, and what you would do differently for this patient. Practise applying a guideline to a patient who does not meet its inclusion criteria.
The candidate describes reflective practice as a box-ticking exercise ('I learnt the importance of communication') with no specific incident, no exploration of their own contribution, and no change in practice.
Reflection is often assessed through portfolios that reward formulaic entries, so trainees write what they think is expected rather than examining a genuine difficulty; they may also avoid disclosing mistakes for fear of consequences.
What to do instead
Keep a short log of specific incidents with what happened, what you felt and thought, what you would do differently, and what you actually changed. Rehearse presenting one such incident in a viva, including how you sought feedback and what evidence shows the change persisted.
When a clinical error or near-miss is raised, the candidate focuses on defending their own actions or blaming the system, rather than acknowledging the event, describing disclosure to the patient, and identifying system and individual learning.
Candidates fear that admitting error in an examination will be judged as incompetence, and they have limited experience of formal incident review or open disclosure conversations.
What to do instead
Prepare a structured account of a real or simulated error: what happened, immediate patient safety action, duty of candour conversation, incident reporting, and the change made. Practise saying 'I made an error and this is what I did next' plainly and without over-apologising.