Psychiatry STACER Preparation Guide
Primer
The Standardized Assessment of a Clinical Encounter Report (STACER) is a semi-structured examination of Canadian psychiatry resident’s interviewing and consultancy skills. An STACER examination is usually a 50 minute diagnostic interview of a volunteer patient that both the resident and examiners do not know. The purpose of the STACER is to demonstrate your psychiatric interview skills, present a mental status examination, generate a comprehensive DSM-5 diagnosis (and differential diagnosis), a biopsychosocial formulation of the patient, and finally, a comprehensive treatment and management plan.
Think of the STACER as interviewing a patient for the purpose of taking over their care. This means you must gather as much information as possible during the 50 minute diagnostic assessment. The challenge with the interviews and questions on STACER examinations is that it is not the same as what you do in real life when you see patients. In the real clinical setting, we try to know our patients over multiple visits, we have old charts and collateral, and we don't have the pressure of examiners in the room!
General Tips
Before the STACER:
During the STACER:
Be succinct with your questions. 50 minutes is not a long time and goes by quickly!
Even if a patient tells you a diagnosis they have been given, you must re-ask the same questions, and make that diagnosis yourself during the interview!
Don't be afraid to interrupt the patient, as long as you do it in a validating, kind, and empathetic manner.
Keep your questions short and simple. Never stack or chain questions together! (e.g. - don't ask: is your mood ever elevated, irritable, and you don't sleep?)
Go through the major DSM-5 criteria with your patient (especially criterion A, B, and C). Your interview questions need to demonstrate to examiners that you know the criteria (you need to “regurgitate” the DSM in front of the examiner)
Don't just focus on symptoms and the diagnostic criteria. The personal history is just as important, so leave at least 10 to 15 minutes for this!
In the final few minutes of the STACER, do not ask questions like: “Is there anything else you want me to know?” or “Do you have a history of trauma or abuse?” – this could open a huge can of worms and you will not have enough time to explore these adequately with the patient!
Don't Forget
First + Last Name
Confidentiality statement
Psychosis: Command hallucinations, thought withdrawal, thought insertion, thought broadcasting
Safety (SI/HI/driving/children/medical safety – ETOH withdrawal)
Don't forget the basic psychiatric review of systems, which includes: mood (depression/mania), anxiety, psychosis, substances, organic, cognitive symptoms.
Don't Panic!
If you panic or lose your train of thought during the STACER, remember, the goal is to:
Develop rapport with the patient
Get the diagnosis
-
Come up with a management and treatment plan
The emphasis is on competence, not excellence
Patient Types
One of the most challenging parts of a STACER is you are given a random, real patient to do a 50 minute assessment on. Since patient's symptoms may range from being in remission (i.e. - an outpatient) to being very symptomatic (i.e. - an inpatient), this can each present as a challenge in their own way. Here are some common patient “prototypes” that you may encounter.
The "Inpatient"
A STACER with an inpatient can sometimes be easier because there is a clear precipitating factor leading to a hospital admission. This means you can usually formulate the current presentation or reason for admission, and this makes your formulation at the end cleaner.
The "Outpatient"
A STACER with an outpatient can be more challenging because their psychiatric disorder may be in remission, or they may have minimal symptoms. In this case, you may end up formulating the patient's overall course of illness and diagnosis, or their last episode of illness. Pick one thing to formulate, and stick with it. Thus, you will want to get the past psychiatric history up front, as there is no “real HPI.” The easiest way to approach the outpatient is to ask them “when were you last unwell?”
The "Poor Historian"
A STACER with a patient who is vague, tangential, or circumstantial can be very challenging!
If you become confused by a patient's psychiatric history, ask them:
When were you last well, or when did the functional decline begin?
When you were really well, what did you do? What was your premorbid function?
How many times have you been admitted to hospital for a psychiatric problem?
What was the admission for?
What was the admission like for you?
If the patient isn't able to give you a medication history, really try to nail it down by asking specific questions such as:
Is it an antidepressant? Antipsychotic?
Is it [name of medication?]
Did you take the medication reliably all the time?
Get a rough timeline by asking:
The "Crying and Dysregulated"
A STACER with a patient who becomes affectively dysregulated and tearful during the interview can be difficult to manage as well.
Be empathetic and don’t forget to attend to the patient in front of you (give them tissues if they're crying!!!)
Acknowledge when the interview is difficult and patient is having trouble, try to contain the interview as much as possible by asking less affectively laden questions, return back to thse questions when the patient settles
Overall Structure
The STACER lasts usually between 90 minutes to 120 minutes, with the following breakdown of times:
Interview Structure
Time Allocation
Suggested Time Allocation
Section | Suggested Time Allocation | Tips |
Introduction, ID | 3-5 minutes | • Establish rapport |
HPI | 15 minutes | • Do an organized approach to asking symptoms
• You should have a primary diagnosis and differential diagnosis by the end of this |
Past Psych History
Past Med History
Family Psychiatric History
Meds/Allergies
Substances
Legal History | 10 minutes | • Identify predisposing biological risk factors
• Identify treatment options |
Social and Personal History | 20 minutes | • If you don't do a good social history, you cannot formulate a patient!
• Identify predisposing psychological and social risk factors
• Identify personality traits |
Introduction
Explain the purpose of the STACER, and that this is an examination for you and for your own learning
Explain limits of confidentiality
Opening
Ask patient are they an inpatient or outpatient?
Are they voluntary or certified/formed?
What is the working diagnosis they have been given?
What treatment are they on?
Past Psychiatric History
Social and Personal History
Clarifying Symptoms and Diagnoses
Establish the index psychiatric event:
First when you felt you were becoming unwell
First when you were in contact with the mental health system
These two may not always occur at the same time! For some people, they may never remember a time where they were feeling well (hint: might want to think about persistent depressive disorder, traumas, and personality disorders)
For example, if you're not sure whether mood symptoms or psychotic symptoms started first, ask yourself:
Is it schizoaffective disorder? (i.e. - are there clear psychotic symptoms in the absence of mood symptoms for > 2 weeks?)
Is it schizophrenia? Are there prodromal symptoms (i.e. - was there a significant functional decline during high school/university? Did they become more withdrawn? Other prodromal symptoms?)
Substances
Social History
Getting the patient to self-formulate can be helpful!
Discuss the impact of family on relationships
Understand issues from a cultural and family perspective if possible
Child and Adolescent
Some key things to not forget during a child and adolescent STACER include:
Suggested Child and Adolescent Interview Template
Interview portion | Suggested Time | Goals |
Introduction, Patient ID | 5 minutes | • Develop rapport |
History of Presenting Illness (HPI) | 15 minutes | • Have an organized approach to collecting the HPI
• Establish the primary diagnosis (think of the common diagnoses in children/adolescents) |
• Past Psychiatric History
• Past Medical History
• Family Psychiatric History
• Medications
• Allergies
• Substance Use History
• Legal History | 10 minutes | • Identify biological risk factors
• Treatments (biological, psychological, social) |
• Social and Developmental History | 20 minutes | • Identify issues relating to: relationshops-work-school-play
• Personality traits
• If you don't have a social history, you cannot formulate the patient! |
Geriatric
Key things to ask on a geriatric STACER include:
Presentation Structure
After you are finished the 50 minute interview, you will have 10 minutes to consolidate your information. You then have 20 minutes (varies depending on institution) to present the following:
History
Mental Status Exam
Diagnoses
Biopsychosocial Formulation
Management and Plan
Common Problem Areas
Common problem areas in STACERs can occur during:
The interview:
Poor rapport/empathy
Overly structured, checklist questions
Poor time management (leading to poor personal history gathering)
Ignoring affective cues of the patient (e.g. - patient is crying and you appear insensitive!)
Leaving out significant aspects of personal and social history
Poor safety/risk assessment
The presentation:
The formulation:
The management plan:
History
Comment on patient reliability at the outset
Save yourself by mention what you missed on history (but mention it once and then move on, don’t apologize too much!), and also what else you would have liked to collect if you had more time
If you intentionally skipped certain things on history - also justify it (e.g. - “I did not screen for OCD symptoms because it was low on my differential”)
Summarize and synthesize, do not present everything you got from the patient all over again! The examiners were there in the room too!
Don't forget to bring up major safety issues identified on the history
Mental Status Exam
Diagnosis
Present your main diagnosis and differential diagnoses. Explain why you believe the patient meets criteria for the main diagnosis and why the other diagnoses are less likely.
Mnemonic
Use the mnemonic
MAPPSOC
to make sure you don't miss any diagnoses!
M
- Mood disorders
A
- Anxiety disorders
P
- Psychotic disorders
P
- Personality disorders
S
- Substance use disorders
O
- Organic
C
- Cognition (dementia, MCI)
State exactly what you are formulating (“I am formulating …”)
Outpatient: you might formulate their history of recurrent depression, their most recent episode of depression, their chronic depression, their anxiety symptoms, their personality (e.g. - sensitivity to invalidation), or distress
Inpatient: current presentation or admission
Formulation themes for the “psycho” part of biopsychosocial include:
Low self-esteem
Identity issues
Safety/security
Control
Autonomy vs. dependency
Intimacy/sexuality
Trust
Attachment
Loss
Stick with a theme or framework that makes sense to you:
-
-
-
-
Interpersonal: interpersonal themes (grief, dysfunctional relationships, interpersonal conflicts, and role transitions)
Example Biopsychosocial Table
| Bio | Psycho | Social |
Predisposing | • Family hx
• Past personal history of same issue | • Adverse childhood experiences (ACEs)
• Theme | • Adverse childhood experiences (ACEs) |
Precipitating | • Medication non-compliance
• Neurodegeneration
• Addiction | • Theme as above | • Recent losses/changes |
Perpetuating | • Addiction | • Theme as above | • Poor rapport, “under supported in current living environment” |
Protective | • Good health, no drugs, no EtOH | • Insight, psychologically-minded, seeks treatment | • Has supports, ease in establishing rapport |
Management and Plan
Outline your management plan very clearly:
Save yourself: Identify any missing information that you did not get in the interview that you would like to obtain now (shows self-awareness of your limitations)
Safety: Identify any safety concerns (SI/HI, AH/VH, driving risks, risks to children)
Status: Inpatient or outpatient, voluntary or involuntary; what is their capacity to consent to treatment?
Collateral: Talking to patient's family, friends, doctors, social workers for safety assessment or diagnostic clarification
Biological:
Short-term:
Investigations: Blood work (CBC, TSH, B12, electrolytes, extended electrolytes), neuroimaging, urine testing, urine dipstick (if woman of childbearing age), baseline ECG if > 40 years old
Medications:
Start a new medication
Stop a current medication
Switch to a new medication
Titrate medication to therapeutic dose
Continue current medication if it's going well
Intermediate:
Long-term
Substance Use
Psychological
Short-term:
Intermediate/long-term:
Self-help, bibliotherapy
Psychotherapies:
Pick a psychotherapy is relevant for not just the illness, but also the patient
CBT, DBT, dynamic, supportive, group therapy, family therapy, couples counselling, mindfulness, AA, etc.
Family support and interventions
Bipolar disorder: Interpersonal Rhythm Therapy
Depression: CBT, IPT (if there are psychosocial precipitants like losses, role transition, role dispute, bereavement)
Psychosis:
CBT for psychosis, social skills training, cognitive remediation
Borderline personality:
DBT (to build interpersonal skills)
-
Substance Use
What stage of change are they at and could they benefit from
motivational interviewing? Could they use addictions support and rehabilitation services?
Social
Employment Assistance Programs
Job interventions
Finances
Volunteer Organization (pets, animals)
Intensive Case Management
Clubs
Art Therapy
Income assistance
Engaging them to do more meaningful work
Family Doctor, Psychiatrist, Social Work involvement, Counsellor Involvement
Think creatively!
Examples
Case 1
History presentation
Jane Doe is a 17 year old female, single, in Grade 12, who reports symptoms of inattention, low mood, and chronic suicidal ideation for the past 1 year. There are no symptoms of grandiosity, reckless behaviours, or impulsivity. She does not have any symptoms of psychosis such as hallucinations, delusions or
On medical history, she has a hypothyroidism and a traumatic brain injury at age 7 from playing hockey. There is a 1 year history of alcohol use, with withdrawal seizures, blackouts, and overuse. On personal history, she has some questions about her sexual identity and relationships with others. She has thoughts of suicide, but no plan or intent. Home environment is safe and there is no abuse from adults or others in the home.
Management Plan
Save yourself: “I would like to ask more around the patient's relationships and issues around gender identity.”
Safety: Patient has a history of chronic suicidal ideation, but no plan or intent. There are no safety concerns at home, and no concerns about child abuse.
Status: There is no role for involuntary hospital admission and she is suitable for ongoing outpatient care.
Collateral: Talk to the patient's family, friends, doctors, social workers for diagnostic clarification
Biological:
Short-term:
Investigations: Blood work (CBC, TSH, B12, electrolytes, extended electrolytes), baseline ECG, baseline weight/height/BMI
Medications: Start a stimulant medication for ADHD (pick a medication and describe the titration schedule and dosage). Consider anti-craving medications and replacement therapies for alcohol use (pick a medication and describe the titration schedule and dosage).
Intermediate:
Psychological
Short-term:
Intermediate/long-term:
Substance Use
What stage of change are they at and could they benefit from
motivational interviewing? Could they use addictions support and rehabilitation services?
Social
Resources