End of Third Year Decisions

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Darkskies

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I am currently on my last rotation of third year and as the school year closes, I am having a difficult time trying to decide what specialty to pursue. I have it narrowed down to Psychiatry(90% chance of choosing), Internal Medicine(with ID fellowship), Family Medicine, and Pediatrics(seriously only considering the first two). I have an interest in Microbiology so the IM to ID route has always been on my mind. To be honest though, I have found third year to be far less enjoyable than the pre-clinical years and have realized that a medical career is mostly about managing patients, chasing lab values, writing redundant notes on patients, deciphering illegible handwriting, coordinating care, following algorithms, and doing a lot of essential mundane tasks rather than about clinching a diagnosis, thinking over things scientifically, or knowing pathophysiology to the extent that we learned it for the boards.

Although I like the subject matter of Medicine, the actual job requires doing a lot of tedious things and someone who is a fast worker but doesn't necessarily have the best foundation of basic sciences knowledge could outperform someone with great board scores at the typical routine day to day job of a physician. Note that I am not criticizing the status quo and I realize that these 'mundane' tasks are extremely important to delivering good patient care.

I liked my IM rotation but again it was mostly about efficiency, churning through patients quickly, getting consults, hunting down patient charts, coordinating with ancillary services, and issuing discharges. I also am not very keen on procedures and my time spent in the ICU showed me that IM residency would still require performing a considerable number of them. Even though I can remember minutiae from the pre-clinical years, it was hard for me to remember and keep tabs on every little thing affecting the 20+ ICU patients. It is offputting that in IM residency I will likely have to spend months in the ICU as well as Surgery on my off-service time. ID physicians(and many IM attendings in general) don't do any procedures so IM residency with its various procedures just seems like another hoop to jump through before I can get to my goal which would also be a poor financial decision(ID physicians make less than General IM).

I am considering FM because it is more outpatient, seems to require less procedures than IM, and also contends with a significant amount of Psychiatry(~20% of patients). I am considering Pediatrics because it is rare to have pediatric patients with 20+ medical problems, would still allow me to practice 'real' medicine, has fewer procedures, and could be an 'easier' route to an ID fellowship although I am neutral to working with kids.

Psychiatry has been vying as my first choice since even before I began medical school. I suppose one of my qualms with choosing it is that I would eventually forget my medicine. To be honest though, that doesn't really concern me so much as the nagging feeling I have of whether Psychiatrists(and psychotropics) truly help patients instead of being ineffectual, or at times even harmful towards patients. I am not trying to criticize Psychiatry so much as wanting to have these guilty concerns of thinking that if I pursue Psychiatry, my work will be meaningless/unhelpful assuaged. It also seems as if even if I wanted to practice Psychiatry the 'right' way, the manner in which mental health services are set in place does not really allow for anyone to work outside the system or the status-quo.

The following posts by skpsycho back in 2008(http://forums.studentdoctor.net/threads/psychiatry-a-good-career.500442/) really had me concerned because he seems like he was an insightful, intelligent, Psychiatry resident(he later quit) who saw serious issues with the way Psychiatry is practiced in the US. Also, no one truly wrote cogent arguments to counter his points. Please note that I am not trying to fan any flames or criticize Psychiatry but in fact only to have my doubts cleared up so I can choose Psychiatry with a clear conscience and much enthusiasm!

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nitemagi said:
I think your logic has difficult consequences. <...>
It's easy to critique psychiatry from the sidelines. And there's plenty to critique, throughout all of medicine. But work in it for a little while before you badmouth it. Either that or pick up a torch and work hard to make changes in the world, rather than just dismissing practices outright.
Thank you for such a thoughtful response. As I've already noted in my response to OldPsychDoc, I am not at all a sideliner to psychiatry. And if badmouthing was an issue, it would hardly be worth wasting the time of the reputable people on this forum. I don't aim to change the world, however. The point of my joining this forum is to see, by way of discussing it with other people, whether I am fit for this profession in this country today.

It is quite clear to me, as a result of my life and professional experience, that many of today's psychiatry practices are wrong. (Especially if you look at things in perspective, and not from a point of view of an overworked resident being thrown feces at by the patients.) Everyday behavior is pathologized, mental issues are superficially understood, people are recklessly put on cocktails of medications with horrible side effects, the research is for-profit and therefore laughable, and psychiatrists, instead of reading Camus and Socrates, spend their free time dining with drug reps.

Exactly why it is so is of no concern to me at this time. There are always explanations. Perhaps it is because of poor infrastructure; or because the doctors are overworked; or maybe something else is the reason. But it is going on, and what I need to understand is whether there is a way around it. In other words, whether I will be able to practise within the system, but in a different fashion.

At the very least I need to ensure that I can reach at least some kind of understanding with my colleagues. So far the experiences on this forum are not very promising... attachFull192156

You make some great points that I would like to comment on.

1. Medicine is largely a field of maintenance and doing the best with the tools we have. How many specialties actually FIX a problem. I could argue almost none, without causing their own problems. Surgery seems like a quick fix except for those lifelong adhesions and abdominal pain. Antibiotics might seem like a fix but really we're just restoring a balance temporarily, often for individuals with recurrent infections. Psych is no different. It's a field of weighing risks and benefits, and when someone comes in suicidal and says help me in some way or I'm going to end my life, and you have tools that might help --- then saying let's wait to give something to keep this person from dying until we understand every intricacy of the brain is frankly LUDICROUS and unethical, especially when there IS data that medications can help.
Still, psychiatry is different. Someone with acute peritonitis requires an immediate surgery, it is the only way to save his life. Yet, someone with acute suicidal intentions does not require haloperidol or an SSRI in the same way. You can help him by providing a safe and pleasant place to be (not to be confused with a psychiatric ward), a qualified sitter, and time to recover. You can then help him deal with the problem that caused his suicidal ideas (there's always one). The reason why you do not do all this, and give the pill or electroshock instead, is because you don't have the resources, or the time, or the skills. This is, of course, the reality, and I don't deny it.

2. Depression is at least the 4th highest cause of disability worldwide - https://content.nejm.org/cgi/content/extract/338/20/1475
Not attempting to use any and all means of helping individuals that are suffering is sad. And I'm not just talking about medications. I know of few psychiatrists who believe that giving medications will fix every problem in those with mental illness. There are many levels, including environmental, philosophical, and otherwise, all of which ideally we should aim to improve in some way.
Agree. What analyses like this one fail to realize, though, is that it is the treated depression that is the cause of the disability - because every recognized case of depression is treated nowadays, and the unrecognized cases aren't counted by statistics. It is the same type of misconception as when some people still believe that schizophrenia is the cause of the weird orofacial movements.

3. Depression may have benefit for some people, but not all and not always. I'm very in favor of Frankl's logotherapy and recommend it often to patients, but that doesn't mean that they will have the energy, motivation, or insight to be able to utilize it properly at the time. It's a tool and a direction to maximize the state, but is not the only valid perspective on depression. It's like those arguments from the scientology community that all depressed people really need to do is just exercise. I love exercise, and I think it helps my mood for sure. But how many people in a full blown major depressive episode do you think you can motivate to exercise daily? Maybe with a multi-system approach of meds, environmental changes, psychotherapy, then they'll be functional to add in exercise, but unlikely to happen alone.
You are quite right. To recommend exercise to a depressed person is no less simplistic than just prescribe a pill. Again, we must understand it in broader sense. The very image of depression in the society must become less superficial and mechanistic. Until then, you're pretty much left with the pill, because, let's face it, people don't care about environmental changes. What they need is a quick-fix to go back to work.

4. Antidepressants may be overprescribed or misprescribed, but I think it's inappropriate to blame psychiatrists for that. I believe it's a tool again, but that most psychiatrists use it appropriately. I think a large problem is that PCP's are often burdened trying to manage depression, much of which may not require antidepressants, and much of which is band-aiding of difficult social situations put on PCP's attempting to do whatever they can to help a patient.
Well, I've worked in an adolescent psych ward of an ivy-league hospital for 2 years. The velocity and thoughtlessness with which psychiatrists prescribe loads of antidepressants and atypicals for 12-13 year olds is no less than amazing. Maybe it's just my hospital (among the 10 best in the nation).
5. 40% of ALL medications effects (psychiatric and otherwise) is placebo. Does that mean don't give the meds because they're only a little better than placebo? No. I'd give someone a jolt-cola enema if I believed it was a tool that would help improve their mental illness. As physicians we should be using all the tools at our disposal, including medications.
Again, I cannot but completely agree. But, you see, in practice, for whatever reason, this phrase seems to be transformed into "all the tools at our disposal, and above all medications". And your logic about placebo is right, but psychiatric meds are no placebos. They have powerful effects apart from those that we seek, and they tend to make our patient's lives miserable sooner or later.

Please understand that I am not criticizing anybody. We all work within the constraints of the system, and we all at some point have to put our noble aspirations on the back-burner. It is more of a matter of a personal preference. For example, soldiers sometimes kill people. It is always a noble doing, and it is always for a reason. Still, I wouldn't like to be a soldier, because I think killing people - in general - is bad. So the question is, would I like to be a psychiatrist, given the current state of affairs?

Thank you for the opportunity to discuss these things.
-----------
skpsycho (http://skpsycho.wordpress.com/)

nitemagi said:
I think you mean soteria, as opposed to satoria, which is similar to Satori, a japanses buddhist word for that "a-ha" experience (often used in Gestalt psychology)
A rather nice Freudian-style wishful thinking on my part attachFull192157 Thanks for the correction.

So Soteria houses and other similar treatments are probably effective in at least some patients. Just as medications are. But should this treatment be adjunct to medications, or may the medications be adjunct to Soteria-type treatment? Depends on how you look at it. From the socioeconomical standpoint, medications are more cost and time-effective, but from the point of view of a human being going through a psychotic episode Soteria is probably better. Because, after all, you put it very well elsewhere that in many cases our psychiatric interventions are only a means of keeping people on the verge of a more serious trouble, until they are capable of sorting things out by themselves. So both meds and Soteria could serve this purpose; the choice is based on socioeconomic factors.

But again, meds have side effects. And even though they work faster, their long-term prognosis is rather gloomy in many cases.

As for your experience on the adolescent ward, I think we can all acknowledge that the system is flawed and that Child/Adolescent psychiatry has more trouble than many. <...>
This is really a critique of Western Society, rather than psychiatry. <...>
You make an interesting point. In a way, I am criticizing Western society. Not so much criticizing it even, but just describing it the way I see it. It seems to be a rather difficult place to live... But, incidentally, eugenics and the like are not at all necessary to correct this. It is as if a teacher kept complaining that they send her only the bad pupils, and demanded constantly to take all the 'F' students away and send her new, good students, so that her class has good grades. It is nothing but a displacement of the problem; in fact, it is the teacher's job to make good students out of whatever she gets in the beginning. In the same way, it is the society's job to grow good people, so to speak. And America is, and has been, failing to do it, choosing instead to displace the blame onto the 'unfit'.

But I think it's somewhat short-sighted to blame psychiatry for over-medicating individuals, even kids who are legitimately suffering and spiralling out of control when sometimes it's the only intervention we have the power to make.
Sometimes it is, but other times it isn't. What worries me is that even though the alternatives theoretically exist, they are not so readily used. For example, I've recently witnessed an adult patient first admitted to our psychiatric ward with hallucinations. She had no psychiatric history and was known to be very bright and well-adapted. They tried every single antipsychotic on her, and with each one she grew worse, and worse, and worse. Then they decided to do ECT. After 12 treatments and the total of 2 months in the hospital she lost the ability to speak, wandered around the unit publicly masturbating, and was incontinent. In an informal conversation with the nurses I asked whether it would have been possible to just leave her alone when she came, observe her for a while and not prescribe any medications except for maybe mild sedatives. I said, if I'm a doctor and I want to make such decision, can I? They said no, because the hospital administration would not tolerate this. The hospital's profit depends on insurance payments that mostly cover medications, and so you have to prescribe something on day one. Mind you, this is the hospital in the nation's top ten.

I see tons of patients with long-term, chronic depression, without clear exacerbating factors, and no single insight or change will improve that. They end up hospitalized, and we do what we can to improve their suffering.
I remember someone say "Don't you know what an endogenous depression is? It is a depression in someone who you haven't spoken to long enough to find out why they are depressed." But it's not the point. The point is that we shouldn't take things in isolation, but must pay attention to the whole process. It is always easy to say "Well, now that I have to deal with this and that, I really have no other choice but to do this". True, but if you stop and think for a second, you might find that the current situation is the result of your earlier actions. At some point you did have a choice.

Another patient example. An extremely bright young man of my age was hospitalized to our ward. At some point in his youth he was diagnosed with schizophrenia and given antipsychotics. He developed a debilitating TD, and is now suffering from depression due to social isolation. Well, clearly there's nothing left to do but give him antidepressants, right? Right, but at this point we tend to forget that his depression is completely our fault, and continue prescribing antipsychotics to bright young people who act 'strangely'. Without even so much as waiting for 6 months before a diagnosis of schizophrenia can be officially made.

And for some of these people they just need a little hope. They need the expectation that they can get better, and a new medication might offer them that. Sometimes that's the only thing they'll take hope in. And who am I to deny someone hope?
Hope is a tricky business. You say, who am I to deny someone hope. But who am I to offer it? Max Frei said that "hope is a stupid feeling", because it implies passivity, instead of taking your life in your own hands. How do I know if and when, by offering the patients hope in the face of medications, I may be depriving them of their liberty to trust in themselves?

And why is it that many a patient whom I speak to tend to have the impression, from the conversations with their doctors, that the medicines are their only hope? I really don't mind giving meds to people who want them, despite knowing all the alternatives. What I have a problem with is expecting the patients to make an informed choice while de facto presenting them with only one option. attachFull192158
 

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Do you have any specific questions we can answer for you? I'd be happy to answer any questions you have about the early portions of residency, inpatient psychiatry, and emergency psychiatry (which is what I've seen thus far).
 
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Psychiatry has been vying as my first choice since even before I began medical school. I suppose one of my qualms with choosing it is that I would eventually forget my medicine. To be honest though, that doesn't really concern me so much as the nagging feeling I have of whether Psychiatrists(and psychotropics) truly help patients instead of being ineffectual, or at times even harmful towards patients. I am not trying to criticize Psychiatry so much as wanting to have these guilty concerns of thinking that if I pursue Psychiatry, my work will be meaningless/unhelpful assuaged. It also seems as if even if I wanted to practice Psychiatry the 'right' way, the manner in which mental health services are set in place does not really allow for anyone to work outside the system or the status-quo.

What is it about psychiatry that you actually like (besides hours, job prospects)? I see what you don't like and while it's good to be aware of the cons, the fact that you didn't mention any pros (besides having psych on the radar for a while now) says something.

What do you mean by practicing psychiatry the 'right' way? I've most definitely seen how a competent psychiatrist and the correct medications (which can take time to determine via trial and error) can truly help patients. If you haven't seen this on your rotations, that's too bad, because folks DO GET BETTER. In fact, I can say without hesitancy that I have seen more patients improve on psych than anywhere else. Once I realized this, choosing psych was a no brainer. Zero qualms about there "not being enough medicine" or whatever. I don't think going into psychiatry is something one should be sitting on the fence about, but what do I know?

All of that said, you seem to have a lot going on right now. Keep it simple. Stay positive. Clear your mind a bit because it's second-guessing-pin-ball-wizardry going on up there right now. I hate to repeat myself (because I've said this to others) but trust your gut. That instinct often speaks personal truth. And when it comes to the woes of modern medicine... How you practice medicine, regardless of the field you choose, will be largely on you, your perspective, and the choices YOU make. The B.S. ... well it's everywhere, every job, every walk of life. Don't let that little bit you may get on your shoes every now and then keep you from moving forward.
 
In my short time as a resident I have given an agoraphobic patient her life back with a relatively short course of CBT (going from housebound and experiencing multiple times per week panic to part-time work and a return to school). I have taken multiple depressed patients who felt suicidal on a daily basis and helped them resolve their suicidality, and get to continue working with them to find a way out of their depression. I have prescribed maintenance medication for bipolar and schizoaffective people who, when psychotic, have done things ranging from serious self-mutilation to giving away their life savings to making serious life-threatening suicide attempts. I have taken catatonic patients who could do little more than stare at a wall with tears streaming down their face and mutter incoherent statements and returned them to their previous level of function. I have helped people work through dysfunctional relationship patterns and start turning around their work and home lives, which if nothing else (in at least one case) resulted in drastic improvements at work and more income and leisure time. I have taken personality disordered patients who were being admitted to the hospital multiple times per month and gotten them to a level of stability that they can tolerate intensive outpatient treatment (and really engage) for months at a time; I have also helped them minimize their self-mutilating behaviors. I have helped people detox from addictions that were ruining their lives and the lives of their families, and some of these people have stuck with it and drastically changed their lives.

This is just a free-flowing rundown of a few of the things I have had the privilege of accomplishing in the past years as a resident. As flawed as psychiatry is, I have no doubt that I have helped a lot of people. It honestly angers me when people make overgeneralized and, frankly, dishonest statements like "people never get better in psychiatry" or "psychiatric treatment does more harm than good." Also when you hear such statements, ask for clarification: which treatments, which illnesses? You will often find the person has at best vague and fuzzy critiques, or ignores entire swaths of psychiatric practice.

That said, are there people who I feel like I don't help very much? Yes. Are there times where I wonder if a person has been worse off for their interactions with the mental health system? Yes again. Still, I get to choose how I practice and, if I do good work, can be a force for positive change in those situations where I feel that it is needed.
 
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What is it about psychiatry that you actually like (besides hours, job prospects)? I see what you don't like and while it's good to be aware of the cons, the fact that you didn't mention any pros (besides having psych on the radar for a while now) says something.

What do you mean by practicing psychiatry the 'right' way? I've most definitely seen how a competent psychiatrist and the correct medications (which can take time to determine via trial and error) can truly help patients. If you haven't seen this on your rotations, that's too bad, because folks DO GET BETTER. In fact, I can say without hesitancy that I have seen more patients improve on psych than anywhere else. Once I realized this, choosing psych was a no brainer. Zero qualms about there "not being enough medicine" or whatever. I don't think going into psychiatry is something one should be sitting on the fence about, but what do I know?

All of that said, you seem to have a lot going on right now. Keep it simple. Stay positive. Clear your mind a bit because it's second-guessing-pin-ball-wizardry going on up there right now. I hate to repeat myself (because I've said this to others) but trust your gut. That instinct often speaks personal truth. And when it comes to the woes of modern medicine... How you practice medicine, regardless of the field you choose, will be largely on you, your perspective, and the choices YOU make. The B.S. ... well it's everywhere, every job, every walk of life. Don't let that little bit you may get on your shoes every now and then keep you from moving forward.

Sorry, I should have mentioned the pros of Psychiatry but I've written other posts before where I've alluded to them. I enjoy listening to people, providing advice, working with the underserved, and have always had a profound interest in the humanities as well which I would think ties into the practice of Psychiatry. I did see patients improve on the inpatient setting.

The main reason for creating this thread is that I'm hoping people will provide good counterpoints to the issues raised in skpsycho's comments, two of which are quoted above and explain why they enjoy Psychiatry and how they help their patients..
 
Sorry, I should have mentioned the pros of Psychiatry but I've written other posts before where I've alluded to them. I enjoy listening to people, providing advice, working with the underserved, and have always had a profound interest in the humanities as well which I would think ties into the practice of Psychiatry. I did see patients improve on the inpatient setting.

The main reason for creating this thread is that I'm hoping people will provide good counterpoints to the issues raised in skpsycho's comments, two of which are quoted above and explain why they enjoy Psychiatry and how they help their patients..
Gotchya. I've looked through that thread before as well. Interesting perspectives. Good luck on the hunt.
 
I gave many responses back in that thread (though I was admittedly only an intern at the time :bookworm:

I would make the first decision of whether you want to work with mental illness/mental health. If so, then learn the field as it stands, but be an adult learner. That means eat the chicken and spit out the bones. The field is not evil. It has useful tools. That doesn't mean you have to limit yourself to that. Pick a residency that teaches foundations of therapy, and make that a priority.

As a psychiatrist whose practice is only 30% meds, I prioritize therapy for everyone. But I've created a niche for myself to make that happen. It's very possible to do. It just requires planning.

This is a common gripe with the field, but I truly believe throwing out the biological approach is as short sighted as working only in the biological. There are many types of therapy, and you can find ways easily to incorporate them into your future practice. If you want a little more specifics on therapies to explore, PM me and I'm happy to help in your quest ;)
 
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The main reason for creating this thread is that I'm hoping people will provide good counterpoints to the issues raised in skpsycho's comments, two of which are quoted above and explain why they enjoy Psychiatry and how they help their patients..
I see a few issues with his arguments:

1) We don't have to be able to prevent suicides to be successful. Sure, it would be nice to actually save lives, but there are other metrics that are important and are used outside of psychiatry as well. Improving quality of life, increasing functional independence, increasing time between hospitalizations all matter. So to call psychiatry ineffectual if we don't prevent suicides is wrong.

2) I never understood why this argument is so common, but he speaks as if other people practicing psych poorly is relevant to your practice. That is, so what if some people over-prescribe antipsychotics to kids? I mean, sure, that's bad and we should try to remedy that, but that's not a reason not to go into this field. You can practice properly even if others don't. I can find bad practitioners of every field -- does that mean you shouldn't be in medicine at all?

3) A lot of things he says are wrong, or at least vague twistings of the truth, which are sometimes hard to argue against. But take this example:

"For example, I've recently witnessed an adult patient first admitted to our psychiatric ward with hallucinations. She had no psychiatric history and was known to be very bright and well-adapted. They tried every single antipsychotic on her, and with each one she grew worse, and worse, and worse. Then they decided to do ECT. After 12 treatments and the total of 2 months in the hospital she lost the ability to speak, wandered around the unit publicly masturbating, and was incontinent. In an informal conversation with the nurses I asked whether it would have been possible to just leave her alone when she came, observe her for a while and not prescribe any medications except for maybe mild sedatives. I said, if I'm a doctor and I want to make such decision, can I? They said no, because the hospital administration would not tolerate this. The hospital's profit depends on insurance payments that mostly cover medications, and so you have to prescribe something on day one. Mind you, this is the hospital in the nation's top ten."

This isn't true. Insurance pays for a patient to stay in the hospital for each day, and that includes all associated costs. If you use medications or not, it pays the same. I have had numerous kids that we kept in the hospital for days without giving any medications as we didn't feel they were indicated. Insurance paid for the whole stay the same as for the other kids.

I am enjoying psychiatry. I am learning how to practice appropriately despite what anyone else may be doing, and I am learning how to determine what is appropriate. I am learning about a variety of treatment options, of which medications are only one, and I see how people overall have better lives after such treatments. I see no reason that people should avoid the field as a general rule.
 
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