Inpatient - is it Satisfifying

[TorMed]

I am an MS 1 thinking about specialties. One area that seems appealing in psychiatry would be to work with newly admitted patients with severe disease and seeing them through to discharge. I have a schizophrenic cousin so I am a little familiar with that type of pathology. Her doctors were able to help her live independently and I think that would be very satisfying.

Is that typical of how residents and attendings find working with the seriously mentally ill? Do you find it rewarding in the long term?

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[OldPsychDoc]

There are many of us who do, yes.

 

[heyjack70]

IMO, inpatient is typically higher stress, but more interesting. People come in acutely ill and have more drastic improvement in the hospital, but then you miss out on all the improvement after discharge like ongoing stability, employment, etc. The best outcome is not seeing someone come back. And some patients don't improve fast enough and get committed and sent to the state hospital.

You also have significant percentages of substance abuse and personality disorders that can be difficult to manage, but this is also true in outpatient setting. The difference in the hospital vs outpatient is you can't screen out patients; you take all comers if appropriate for admission.

 

[hamstergang]

I do not much like inpatient work for 2 main reasons:

1) Not terribly much changes from one day to the next. Our treatments just don't work that quickly. At least in outpatient you send the patient away for some time so when they come back things may be different.

2) The precise discharge date always felt a bit arbitrary to me. It felt that we kept patients hospitalized for a day or 2 longer than I thought was necessary, and often for rather vague reasons.

Otherwise, seeing severely I'll patients improve is nice.

 

[Red Beard]

Taking a patient from floridly manic, disorganized, not making a lick of sense, to being able to hold a conversation in a week's time is pretty satisfying.

Watching catatonia resolve over the course of hours is pretty satisfying.

Coming in and working along side/interacting with a fun group of nurses, therapists, social workers, and colleagues is satisfying (compared to working in an isolated private office somewhere.)

Leaving the hospital and knowing that your patients are in a safe place so you can enjoy your free time in the evening and on weekends is satisfying.

 

[slappy]

To me, the most disheartening thing is not seeing little improvement in patients in inpatient settings - I really do see drastic improvements in most cases, and it is satisfying. However, realizing that we likely won't understand in our lifetime the exact pathophysiology of the symptoms we see and treat, makes me very sad. And I think about this a lot more on inpatient units than on outpatient, likely because of the much higher turnover and acuity.

 

[smalltownpsych]

I miss working in an inpatient setting. I especially enjoyed working with group therapy and also the milieu. Give me some young feisty, borderlines upsetting all the staff and I roll up my sleeves and go to work! I get bored working in an outpatient therapy office at times. I was never bored in inpatient. The only reason I am not doing it at this point in time is financial. Fortunately, it gets a bit more interesting the weeks I am on call and about half of my outpatient clients really are in distress or wanting to change.

 

[MacDonaldTriad]

I think inpatient work is both the best and the worst part of psychiatry. The dramatic improvements and leading a treatment team are very rewarding. The legal hassles and paperwork are the worst. If by some miracle society removed 90% of the checks and balances and let us do what we think needs doing, I would be all into it. Of course I’m not advocating that, no one should have that kind of power.

 

[shan564]

1) Not terribly much changes from one day to the next. Our treatments just don't work that quickly. At least in outpatient you send the patient away for some time so when they come back things may be different.

2) The precise discharge date always felt a bit arbitrary to me. It felt that we kept patients hospitalized for a day or 2 longer than I thought was necessary, and often for rather vague reasons.

I think those are both things that can vary by attending and by treatment strategy. I agree that our treatments don't work as quickly as they do on internal medicine, but sometimes I feel like we're going too slowly in an outpatient setting. I like that you can uptitrate meds much faster as an inpatient, and if the patient has side effects, you can manage them as you go along.

Also, I think that the arbitrary nature of the discharge date is very attending-dependent. We tend to discharge faster at my institution than at some other places for that reason. If the patient is at a point where you wouldn't admit them if you saw them as an outpatient or in the ER, then that means that they could be managed as an outpatient. They should always be managed in the least restrictive environment possible... if the patient has strong family support and close outpatient follow-up, we might let them go before the psychosis is completely clear; if they have no support whatsoever, they might need to stay a bit longer or go to a group home.


I definitely agree that inpatient is "the best and the worst." And I think that's why very few people do 100% inpatient work - most people do some sort of hybrid.

 

[OldPsychDoc]

I think inpatient work is both the best and the worst part of psychiatry. The dramatic improvements and leading a treatment team are very rewarding. The legal hassles and paperwork are the worst. If by some miracle society removed 90% of the checks and balances and let us do what we think needs doing, I would be all into it. Of course I’m not advocating that, no one should have that kind of power.

But if anyone did, it should be you!

 

[vistaril]

I like that you can uptitrate meds much faster as an inpatient, and if the patient has side effects, you can manage them as you go along.
.

There is little value in this though. The medications that we start on an inpatient unit, with the possible exception of meds for acute mania, do little to actually help the patient and cause improvement while the patient is there(unless it's a ridiculously long stay). Given that, what's the rush and need to be aggressive?
One way inpatient psychs can benefit the patient in a short time period though is sometimes stopping harmful meds. I work some inpatient psych now and I routinely discontinue certain meds that I feel are contributing to the patient being oversedated for example.

 

[whopper]

Here's what I like about inpatient.

If you got a good treatment team they can be like family.
You can see psychiatric pathology at it's extremes and see people get better fairly quickly if you start the right treatment.
Once you leave work, work is usually over and done with until tomorrow. In outpatient your patient could call you at any time in a very annoying and troublesome manner ("Doctor! My football team lost, what are you going to do about it!?!?!?" Me-I'm going to hang up the phone).

 

[hamstergang]

If the patient is at a point where you wouldn't admit them if you saw them as an outpatient or in the ER, then that means that they could be managed as an outpatient.

See, this is what I would like it to be like, but too often I see the bar for discharge being higher (less severe, more functional) than the bar for admission. It's nice to know that's not the only option. Do you find, though, that these quicker discharges lead to more readmissions? That would be my fear, that we haven't properly and fully prepared this patient to return to the community (even if they're also going to a partial program next).

 

[Shikima]

Here's what I like about inpatient.

If you got a good treatment team they can be like family.
You can see psychiatric pathology at it's extremes and see people get better fairly quickly if you start the right treatment.
Once you leave work, work is usually over and done with until tomorrow. In outpatient your patient could call you at any time in a very annoying and troublesome manner ("Doctor! My football team lost, what are you going to do about it!?!?!?" Me-I'm going to hang up the phone).

I've now trained all my Pt's to call during business hours unless it is an emergency then just pass go and forget the $200 smackers......

 

[NickNaylor]

I'm more limited in my experienced than my learned colleagues above, but I've done one month rotations in both consult-liason and inpatient and enjoyed both. Inpatient is satisfying for the reasons mentioned above; much like any sort of inpatient service, you have the opportunity to see incredible changes in patients' functional status. You also, unfortunately, see patients that don't seem to improve no matter what you do. C/L is enjoyable because I like the role of being a consultant; I think it's fun to discuss a patient in the context of other issues going on with them and serve as the "expert" for a particular aspect of a patient's management. However, I also found it to be somewhat boring as the cases were largely delirium, depression, etc.. Rarely would people be floridly psychotic or otherwise symptomatic, though there were a few cases of that. The relatively quick turnover can also be a nice change from seeing the same patients for days or weeks at a time.

 

[PistolPete]

I didn't really like inpatient because I came in (like most patients) thinking that SO MUCH would happen, so much treatment would occur... and at the end of the day, the patient speaks to the psychiatrist for 5 minutes per day, gets some meds upped after a few days, goes to some groups, and is discharged in 3, 4 or 5 days... maybe they're kept for a more extended period of time if they're truly manic or psychotic and you see more change, but that's it.

I feel that most treatment occurs in outpatient or partial hospitalization settings, which is why I want to focus my work here.

 

[whopper]

IMHO everything in psychiatry has it's pros and cons whether it's outpatient, inpatient, forensic, substance abuse, etc.

The way I work, I like doing a mixture of everything. It keeps me up and prevents me from getting demoralized at work. If I did just one thing all the time every single day I think I'd get sick of it.

But if I could only do one thing it'd be inpatient. IMHO and this is just me, it's the backbone of psychiatry because we see very significant pathology and we see it get better relatively quickly.

 

[slappy]

Also, inpatient psychiatry is not that challenging is it? Even as a PGY1 when my attending let me completely manage all the patients on my own, it was never overwhelming. Diagnostic complications are far and few between, and even then, we only have a handful of drugs to treat them all. Psychotherapy is virtually nonexistent, except perhaps supportive psychotherapy, occasional motivational interviewing, and brief psychodynamic psychotherapy (rarely).

 

[notdeadyet]

Also, inpatient psychiatry is not that challenging is it? Even as a PGY1 when my attending let me completely manage all the patients on my own, it was never overwhelming.

It gets more challenging when you get better at it. That's why it's an excellent learning environment for interns: they can scrape the surface and toss antipsychotics at folks at the end of the learning curve, but it becomes more challenging when you're working in an environment like that longitudinally.

 

[heyjack70]

Also, inpatient psychiatry is not that challenging is it? Even as a PGY1 when my attending let me completely manage all the patients on my own, it was never overwhelming. Diagnostic complications are far and few between, and even then, we only have a handful of drugs to treat them all. Psychotherapy is virtually nonexistent, except perhaps supportive psychotherapy, occasional motivational interviewing, and brief psychodynamic psychotherapy (rarely).

I disagree with this. Sure there's bipolar, schizophrenia, depression, ptsd, anxiety, etc etc. But in addition to the bread and butter cases, the mixture of substance abuse, personality traits/disorders, cognitive disorders, head injuries, factitious, malingering, and otherwise complicated issues serve to create not infrequent diagnostic dilemmas on the inpatient unit.

 

[shan564]

There is little value in this though. The medications that we start on an inpatient unit, with the possible exception of meds for acute mania, do little to actually help the patient and cause improvement while the patient is there(unless it's a ridiculously long stay). Given that, what's the rush and need to be aggressive?
One way inpatient psychs can benefit the patient in a short time period though is sometimes stopping harmful meds. I work some inpatient psych now and I routinely discontinue certain meds that I feel are contributing to the patient being oversedated for example.

If a patient with schizophrenia has been off antipsychotics for a while, you can get them better pretty quickly, even if you haven't reached the full effect. Not sure about your geographic area, but that probably makes up quite a significant chunk of the people on our inpatient unit.

Also, just because you don't see the response during the inpatient stay doesn't mean that it doesn't happen. If you go up on meds faster, the patient gets better faster, even if it doesn't happen in front of you. I don't see the point in condemning the patient to a couple of extra weeks of depression just because I'm worried that Celexa will make them nauseous and tremulous for a couple of days. I usually discuss this risk/benefit with patients (if they have capacity to make the decision), and most of them prefer that way... although I'm sure that some part of that is the way in which I present it.

So in short, the rush is because severe mental illness is painful, and I want to end that pain as quickly as possible.

See, this is what I would like it to be like, but too often I see the bar for discharge being higher (less severe, more functional) than the bar for admission. It's nice to know that's not the only option. Do you find, though, that these quicker discharges lead to more readmissions? That would be my fear, that we haven't properly and fully prepared this patient to return to the community (even if they're also going to a partial program next).

Of course, you have to strike a balance. Obviously discharging too fast would increase the risk for readmission, but I think there's a point of diminishing returns after which a longer stay doesn't improve long-term outcomes.

 

[slappy]

It gets more challenging when you get better at it. That's why it's an excellent learning environment for interns: they can scrape the surface and toss antipsychotics at folks at the end of the learning curve, but it becomes more challenging when you're working in an environment like that longitudinally.

I simply don't see it. On the other hand, I could see psychotherapy, and building long-term rapport with the patient, challenging. But not most inpatient work, including most of the ones heyjack70 had listed. There are good diagnostic scales for a lot of them (which are generally underused), and worse comes to worst, you can fall back on old records, or even neuropsych testing. I agree it can be quite rewarding to see patients get better quickly, but that's pretty much where it ends for me.