Psych-cations and a Med Student's Slight Identity Crisis

[throwaway20425]

TLDR: The culture of psychiatry rotations at my school has made me scared of what psych residency might look like for an uncompetitive psych applicant who is maybe too idealistic.

Greetings all,
I’m a DO student finishing up my third year. Before med school, I had several years of experience in dual diagnosis treatment, as well as with SMI in my immediate family; I loved this work and I came to med school to become a psychiatrist. However, after completing two psych rotations, I feel disheartened and am questioning my future. I’d appreciate some perspective on whether this stems from my own naivety or if it's a result of the particular experiences I've encountered (or perhaps both), as well as what this might mean for residency ahead. I probably also need to just vent a bit.

I know psych rotations are often referred to as “psych-cation”. However, I thought I'd be able to opt in, to engage and learn more on these rotations given my excitement about this work. Instead, I've learned that, in the case of my school's rotations, there is not additional work to opt in to. Most of the psychiatry preceptors for my school work "full time" at multiple facilities, earning staggering salaries while providing what I consider to be substandard care. I'm talking about no intake evals on new inpatient SMI admits, just copying forward an H&P and calling it a day, sub-1-minute follow-ups (I truly have timed it), or just skipping follow-up entirely but writing a note anyway. I feel upset that I'm complicit in the poor care they're providing. I'm learning very little on the job. I'm not getting support or mentorship through some of the challenging experiences I've had.

Of course, I knew that there were providers like this out there, but I never expected them to be working in academic medicine or serving as preceptors. I didn’t realize how much I crave mentorship until these rotations showed me what it’s like to be without it. So now, I’m worried about experiencing something similar in residency.

Can any of y’all speak to experiencing apathy like this from attendings or other trainees in residency? Are there programs where it's normalized to practice medicine to this standard? How can I identify and avoid programs with this culture, short of participating in audition rotations? As a middle to low-stat DO applicant, I'm realistic about the sort of residency program I might end up at, and I’m apprehensive now that I’ll be relegated to a program that doesn’t align with my values.

I feel disappointed and worried. I'm not sure if I could handle the moral injury of a whole residency that is like these past two rotations.

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[jbomba]

Do you want to potentially be a psychiatrist at a program that may not align with your values for four years or do you want to be a *shudders* family medicine doc?

 

[TexasPhysician]

That is not common in academia at all. Never saw that in my training.

 

[dl2dp2]

That is not common in academia at all. Never saw that in my training.

I did this myself while as a moonlighter at a community satellite lol. Not my best work and cemented my decision to not do inpatient.

It is possible to deliver high-quality care. But it's not possible to make a lot of money unless you go OON. This is reminiscent of the overall healthcare system. Quality, access, affordability. Pick 2. So yes there is a drop of quality with 1 min followups. But perhaps it's "adequate" for a community inpatient unit? I don't know. Not on the QA committee, and have zero interest in this. I decided to pick quality and access, but it necessitates that I am uber-expensive. I have SMIs in my practice. Life is about making choices.

 

[Stagg737]

Agree with above that this is not typical. I had an attending in medical school who saw 40+ patients per day and even he somehow found time to be a decent teacher and discuss diagnoses, med plans, and general treatment with us. Some preceptors are just awful, but a program full of them is a massive red flag. The part quoted below is particularly concerning though:

I'm talking about no intake evals on new inpatient SMI admits, just copying forward an H&P and calling it a day, sub-1-minute follow-ups (I truly have timed it), or just skipping follow-up entirely but writing a note anyway. I feel upset that I'm complicit in the poor care they're providing.

The bolded especially is an unacceptable level of care and is likely fraud if they're using them to bill. The copying forward can be acceptable in some situations if documented correctly, but they could get in a ton of trouble if they're writing notes saying they saw patients and billing for it when they never did. It's the only time I know of a psychiatrist actually being fired from a VA.

 

[comp1]

First and foremost, ~80% of psychiatrists practice only outpatient psychiatry. I would argue that medical student experiences are roughly the inverse, so it doesn't quite represent what people actually do regardless. Copying and pasting (without citation) is inappropriate, but rampant throughout medicine. You're likely noticing it more here because of interest in psychiatry. I would argue that 1 minute evaluations are usually inappropriate, but if a patient is screaming that they are going to rape and kill me or completely catatonic, I'm also not going to just stand around and try to get more information from them, nor should you, particularly as a student. Further, quantity of time with a patient is NOT a measure of care, most particularly for inpatients. In general, the goal of inpatient care is acute stabilization followed by connection to resources. Acute stabilization is often pretty darn easy, but it's probably what you're spending most of your time learning since you're new. I promise you, the allure of choosing between olanzapine and risperidone wears off eventually. Connection to resources is where the art and beauty of inpatient psychiatry lies. It's NOT just social work's job. You are the leader of the team, you should be directing the social workers (after training) and if you don't know what they're doing or why, it's going to be substandard. Maybe meet with other members of the team, particularly nursing. The residents and attendings should be a relatively small part everything going on with inpatients. In terms of choosing a residency...whatever you experienced seems uncommon in academic settings. If it's something you're really concerned about, you likely want to try residencies that have an internal psychiatric hospital they own and run as opposed to sending attendings as contractors to a private hospital. But like you alluded to, psychiatry is extremely competitive and for good reason. I would say match where you can. It'll all work out.

 

[Merovinge]

Hate to be the one to say it, but this type of experience is going to happen a lot more with DO and Caribbean med school students than MD training. There are plenty of good DO schools but some that just have very poor clinical rotations setup for their students. I don't think anything you are describing even relates to the field of psychiatry, you are just running into fraudster docs (of which every field has some) who are voting for team green rather than actually doing their job or caring at all about anything resembling the job of being a physician/medical ethics.

The good news for you, is that you get to leave the site after a few weeks, go do some non-psychiatry (hopefully with a better training environment), and know that 99% of psychiatry residencies are going to look dramatically better than your experience to date. The best part of being at the bottom of the glass is that everything from here on out will be up.

 

[comp1]

Oh geeze, I missed the DO part!!! That is so crucial. DO clerkship rotations are truly patchwork with EXTREME variations in quality. I've seen extremely desperate schools seeking sites. They are are NOT representative of the average US MD clerkship or certainly psychiatry residency training. DO schools often pay private sites to let their students rotate through. It's can be just another check. Further, your attendings are likely not the ones being compensated in any way to, um, manage you. The check likely went to the hospital or some department within it.

 

[calvnandhobbs68]

Hate to be the one to say it, but this type of experience is going to happen a lot more with DO and Caribbean med school students than MD training.

Yeahhh I was actually gonna say the same thing. I've heard of a lot of DO schools with really terrible/variable rotations, so this is likely a function of some "academic in name only" rotation site.

 

[Celexa]

Others have given you good answers so I will be brief, but no, what you are seeing is not typical for a training environment. It also doesn't sound like actual academic medicine. Academic medicine means more than having medical students or even residents around--it general means an institution with an explicit triple aim (clincial care, teaching, and research).

There are lots of rotation sites, particualrly if they are placements for students and not also residency training locations, that are not truly 'academic' environments.

If psych feels right for you despite your current settings it will almost certainly feel even better in a higher quality care environment! If you can, I would try and obtain an away rotation at a clincial site with residents. Look at academic institions that have DOs in their residencies.

 

[Stagg737]

Oh geeze, I missed the DO part!!! That is so crucial. DO clerkship rotations are truly patchwork with EXTREME variations in quality. I've seen extremely desperate schools seeking sites. They are are NOT representative of the average US MD clerkship or certainly psychiatry residency training. DO schools often pay private sites to let their students rotate through. It's can be just another check. Further, your attendings are likely not the ones being compensated in any way to, um, manage you. The check likely went to the hospital or some department within it.

So I'm a DO at an academic hospital with an associate MD school. Tbh, the exposure and education I got in my DO rotations was very solid and better than several of my MD colleagues from the experiences we've talked about. One of them described their MD experience to be somewhat similar to the OP minus the potential fraud (attendings leave well before noon and become completely unavailable to students and residents). I was quite fortunate in both breadth and quality of my psych education in med school, and it showed in my early evals in residency.

Like you said this is highly variable and totally dependent on the schools. Some DO schools really do a horrendous job with their clinical years and there were one or two that actually had the medical students setting them up at one point. It's a pretty open secret in the DO academic community which schools are bad during those years and it's easy to find on this site. That's also not typically how the supervision pay works for these rotations, but I'm sure it's true for some. That being said, there are also some DO schools do have affiliated hospitals where all their students rotate during clinical years like the standard MD experience. Imo biggest advantage there is how to function in a team with rounds as opposed to more individualized supervision/small teams.

TL;DR is I wouldn't jump to the conclusion of a terrible preceptor/rotation just because OP is a DO, but also doesn't surprise me given the lax standards of COCA for clinical rotations.

 

[MacDonaldTriad]

DO bashing is a generalization, but may be generally true in some cases but there are many exceptions. The recent addition of for profit allopathic schools should face the same criticism and may be guilty or not. If your education doesn't have graduate PhD students teaching your labs, if your medical school doesn't run a large hospital, or a network of hospitals, don't be shocked that you are left to find your own clinical experiences. If you find yourself "shadowing" an "outpatient practitioner" that is voluntary and not paid to teach and not trained to teach and is just showing you about what their day is like, you will find the experience worth every penny invested. Buyer beware. Measure the responsibility you are pushed into filling uncomfortably and get better at. If that is lacking, so is your education. This may be brain surgery, but it isn't rocket science.

 

[comp1]

There are great DO schools and yes, the for profit MD schools are concerning. Like I said above about residencies, the OP is, in general, less likely to have this experience if a hospital, particularly a psych hospital, is formally attached or associated with the university. In my experience, this relationship is much, much less common in DO schools which tend to seek out clerkship experiences all over. Concerningly, the new for profit US MD schools (and all Caribbean schools by definition) are structured similarly. Am I wrong about this? My experience with DO schools is mostly limited to the West Coast. I know in the Midwest they tend to be more established.

 

[annoyedpsychiatrist]

I serve as a preceptor for two major residency programs (not psychiatry but other fields of medicine) and two medical schools for third years. I do the best I can to give students a good experience, but some days are busier than others. Ultimately there are good/bad docs in every field of medicine. Burnout happens. Ive felt burnt out many times. Some weeks im in a good state of mind, other weeks ive just seen 10+ "i dont want to give pt their xanax anymore, refer to psych" and the burn out creeps in.

Regardless, you choose what you do in your field. For me, i acknowledge I have gaps. Im constantly trying to fill those gaps. As an attending of 3 years, the learning process is neverending. Hell, was doing some Uworld questions the other day, missed a few and had a major "wtf" moment, lol. Poorly worded questions in my defense...

My point with the above, is in psych you get what you put in. You choose how good you want to be. Residency was very resident driven with limited hand holding but I thrived in that environment because it motivated me to rise and grow. Do not count on others to fulfill you or help you grow, you have the power yourself.

 

[Candidate2017]

I’m a DO student finishing up my third year. Before med school, I had several years of experience in dual diagnosis treatment, as well as with SMI in my immediate family; I loved this work and I came to med school to become a psychiatrist. However, after completing two psych rotations, I feel disheartened and am questioning

Transference. Watch for it.

Most of the psychiatry preceptors for my school work "full time" at multiple facilities, earning staggering salaries while providing what I consider to be substandard care.

They showed you their W-2 salary? Staggering salaries compared to whom? The CEO? You are qualified to speak on the standard of care, because?

I'm talking about no intake evals on new inpatient SMI admits, just copying forward an H&P and calling it a day, sub-1-minute follow-ups (I truly have timed it), or just skipping follow-up entirely but writing a note anyway. I feel upset that I'm complicit in the poor care they're providing. I'm learning very little on the job. I'm learning very little on the job. I'm not getting support or mentorship through some of the challenging experiences I've had.

No actual H&P? I doubt it. Because nurses. They love throwing people under the bus for real or imagined offenses. Throw in that sweet federal whistleblower money, and nurses can't resist. Heck, call the feds yourself.

As with any medical complaint, most H&Ps aren't that unique. Pull one off the shelf. CP, ASA, EKG, trops, CMP, BB, F/U OP. Easy peasy. This is why we're experts. It's easy to us. For acute SMI inpatient follow up and stabilization, it's not the minutes you spend, but the milligrams of FGA/SGA you dispense.

And no, you are not complicit in poor care, or any care. You're a student. Your job is to read and observe. How many thousands of hours does a baby observe and learn before it says its first words? Its first coherent question?

What's so special about you that you feel the doc owes you mentorship, which is an organic process? What's so challenging about showing up to a psych rotation, reading, observing/learning, not being a jack, and not interfering with patient care?

As a middle to low-stat DO applicant, I'm realistic about the sort of residency program I might end up at, and I’m apprehensive now that I’ll be relegated to a program that doesn’t align with my values.

I feel disappointed and worried. I'm not sure if I could handle the moral injury of a whole residency that is like these past two rotations.

Middling low students end up in middling low programs, become middling low attendings who precept middling low students who complain about middling low attendings. This is the cycle. Unless you work out some of your cognitive errors.

 

[Candidate2017]

Regardless, you choose what you do in your field. For me, i acknowledge I have gaps. Im constantly trying to fill those gaps. As an attending of 3 years, the learning process is neverending. Hell, was doing some Uworld questions the other day, missed a few and had a major "wtf" moment, lol.

Wait, what?

 

[annoyedpsychiatrist]

Wait, what?

uworld question bank for step 2. I was doing some questions with the student im working with . Sometimes ill do questions with the student to help them get in the right mindset of formulating a differential diagnosis and stuff of that nature. They all get uworld from their school for free to study for step 2.

 

[throwaway20425]

Transference. Watch for it.



They showed you their W-2 salary? Staggering salaries compared to whom? The CEO? You are qualified to speak on the standard of care, because?



No actual H&P? I doubt it. Because nurses. They love throwing people under the bus for real or imagined offenses. Throw in that sweet federal whistleblower money, and nurses can't resist. Heck, call the feds yourself.

As with any medical complaint, most H&Ps aren't that unique. Pull one off the shelf. CP, ASA, EKG, trops, CMP, BB, F/U OP. Easy peasy. This is why we're experts. It's easy to us. For acute SMI inpatient follow up and stabilization, it's not the minutes you spend, but the milligrams of FGA/SGA you dispense.

And no, you are not complicit in poor care, or any care. You're a student. Your job is to read and observe. How many thousands of hours does a baby observe and learn before it says its first words? Its first coherent question?

What's so special about you that you feel the doc owes you mentorship, which is an organic process? What's so challenging about showing up to a psych rotation, reading, observing/learning, not being a jack, and not interfering with patient care?



Middling low students end up in middling low programs, become middling low attendings who precept middling low students who complain about middling low attendings. This is the cycle. Unless you work out some of your cognitive errors.

Not gonna defend myself to someone who has nothing better to do than cyberbully med students. Pretty embarrassing.

Thanks to others who have provided thoughtful feedback. Your perspectives have been very helpful to me.

 

[ObsequiousAplomb]

Not gonna defend myself to someone who has nothing better to do than cyberbully med students. Pretty embarrassing.

Thanks to others who have provided thoughtful feedback. Your perspectives have been very helpful to me.

If you think that's cyberbullying...

 

[comp1]

I don't think the comment was cyberbullying exactly. It is a bit...direct for an anonymous MS3. I definitely agree with us all checking in on our countertransference when working with patients. It's actually something I have to do on this checklist from the school with med students.

 

[mistafab]

“Can any of y’all speak to experiencing apathy like this from attendings or other trainees in residency”

Unfortunately, some schools are desperate to find potential MDs for rotations. DOs in general have a harder time with this than MDs from my experience at several programs.


Given that, your experience is in no way indicative of the field. Seek within yourself if psych is for you. Not every MD or DO you get paired up is taking students for the “right” reasons. Some just take the 2k per year offered by the school, and care nothing about education.

 

[nexus73]

I would try to reframe this rotation as an extremely valuable exposure about how not to practice. This type of rotation you might never get in an ivory tower academic hospital.

 

[Celexa]

I would try to reframe this rotation as an extremely valuable exposure about how not to practice. This type of rotation you might never get in an ivory tower academic hospital.

Oh, how I wish this type of experience never came up at an ivory tower hospital. It's rarer but hardly absent. Granted, usually MUCH rarer on teaching services comparatively.

But I agree that medical school and residency inevitably include both lessons in how you will want to pracrice, and how you will not. Both matter.

 

[Merovinge]

Oh, how I wish this type of experience never came up at an ivory tower hospital. It's rarer but hardly absent. Granted, usually MUCH rarer on teaching services comparatively.

But I agree that medical school and residency inevitably include both lessons in how you will want to pracrice, and how you will not. Both matter.

So does being an adolescent if you can squeeze a tiny time for reflection from your parents' parenting (or lack thereof for many of my patients). As do any longer term romantic relationships. Lessons on how not to do something feel very left out of the zeitgeist, but in many ways can be even stronger than positive role models.