Hello

I started third year with Surgery, which didn't go as well as I wanted it to go because I felt very intimidated by the residents/attending and I just had no clue what I was supposed to do. I did well the first two years of med school, but I feel like this third year thing is gonna kill me! I feel like i'm always 10 steps behind and always seem to be making the wrong decisions, even when the right decisions are screaming out at me!

well, i just had to rant for a second there :) ok..i'm moving onto consult service on psychiatry. I was wondering if any of you guys have some good advice on how to really SHINE on this service. My attending is this really funny guy and seems laid back, but that doesn't mean anything when it comes to how he'll grade me. So i just want to make a good impression, darn it :) i'd appreciate any input! thanks

I feel your pain. I also did well during my 1st 2 yrs, but got killed on Peds and FM. Luckily, I balanced that with great evals in the rotations that count (i.e. surgery, medicine, OB/GYN). Luckily, I had surg last, so it was more enjoyable for me.

For any psych service, a tip that will serve you well is to learn the lingo. Learn to write (and present) a thorough psych note. Pay attention to the detailed stuff like thought process, thought content, etc, and make sure things are where they belong. Consider buying one of those $10 pocket books that has everything outlined/explained. Even if psych isn't your thing, find something you like about it and be enthuastiac.

One thing I noticed about psych guys is that some have the unrelenting need to justify their decision to go into the field. If you have a resident like this, be sure to reinforce him/her in that decision. Whatever you do, DON'T make jokes about psych not being "real medicine". This can burn you (it caused a friend of mine big problems), because psych residents and attendings can be very sensitive to this.

Good luck!

Couple points of advice: shine by knowing your stuff, being interested in learning, being good with patients, and being efficient.

1) Know your stuff: remind yourself (or learn) how to do a mental status exam - this is the meat of the H & P you will be doing over and over on the consult service. Familiarize yourself with psych terms (e.g. tangential thoughts vs. circumstantial thoughts, illusions vs. hallucinations vs. delusions) so you can use them correctly. You will probably need a lot of direction at first because psych interviews tend to have a steep learning curve (they are not like other H & Ps or interviews you've done). The attendings will expect this and will be happy to provide direction: that's fine, just listen carefully and try not to repeat the same mistake twice.

2) Be interested in learning: ask pertinent questions regarding diagnosis and treatment (e.g. "why did we choose Zyprexa for that patient?", "what are we looking for by ordering these labs?"). Be careful not to "overask" (ask a question for the sake of asking a question), or (the worst) ask a question to which you already know the answer to show off. The other way in which you can be interested in learning is to read. Gunners will look up scientific literature articles and learn the latest basic science experiments about the most obscure dopamine receptor subtype. This is great if you have time to burn. A better strategy is reading a book that has good info. My school makes us read "Clinical Psychiatry for Medical Students" (Stoudemire) which is thick but pretty good. In particular psych meds can be tricky at first. If you've done reading you'll be able to impress the attending by knowing important distinctions between similar diagnosis (e.g. how are schizoaffective and mood disorder with psychotic features different? how are schizophrenia and delusional disorder different?) and what side effects of psych meds are (e.g. what is tardive dyskinesia and what is akinesia - they are not the same). Knowing things like this w/o being told will impress the attending.

3) Be good with patients: general good rapport with patients, good interviewing skills (being able to wheedle a history out of a floridly psychotic patient), and being sensitive to psychosocial issues. When the RNs are rolling their eyes and bitching because they've got a "crazy patient", maintain your professionalism and empathy for the mentally ill. They deserve good care too. This will impress your attending. Look up the term "counter-transference" and think about it every time you see a psychiatric patient.

4) Be efficient: the MS exam may take a little longer than listening to a heart and lungs but it doesn't need to take 2 hours either. (Especially as you get more comfortable with psych interviews - the first couple of times take as long as you need, but anticipate the need to streamline things later on). Get the info you need to make diagnostic and treatment decision, assimilate and present the data efficiently. Attendings will appreciate you trying to get them out of the hospital in a timely manner and will probably reciprocate.

Finally, don't worry. Psych is pretty laid back in general and it sounds like your attending is a cool guy. Psych attendings do have a pet peeve about med students who are so focused on their career in otolaryngology (or cardiology, or cardiothoracic surgery, or what have you) that they turn their noses up at psychiatry and the people who work in that field. (Of course, I have met psych residents who do the same about fields like surgery.) Anyway, just don't be one of those people who's so sure that psychiatry is useless that they can't be bothered to learn about it.

Hope that helps.

bpkurtz