What is it slike being a Psychiatrist?

[sniffingposition]

I apologize if this thread is out of place or has a weird title - I'm an incoming MS3 who would like to get an idea of what psychiatry is - I understand there are many different froms, inpatient, outpatient, private practice, foresenic, emergency psych - but my Psych rotation is far off in the Spring and I'd just like see what some people's days are like. What kind of patients come in? How do you interact with them? How do you work them up? What do you do with them afterwards? What are the memorable cases? What are the mundane cases? How do you think when you are trying to approach the patient's issues? Anything along those lines would be great to hear!

---

Members don't see this ad.

 

[heyjack70]

I work in the hospital and see 8-12 people a day, maybe a few more if there are consults. The days with more take longer. Sometimes I leave at 2pm, sometimes I stay until 7pm. It's super interesting working with acutely ill psychiatric patients. The main diagnoses are probably borderline personality disorder, depression, bipolar mania/depression, and schizophrenia, with anxiety disorders mixed in as well. There is also a lot of substance abuse on top of the primary psychiatric diagnosis. You interact with them in a way you interact with most people. But if they are agitated you might give them medicine to calm down, or just interview them from a bit further away or with security present. The psychiatric workup is really based on the psychiatric diagnostic interview where you ask them about symptoms and observe for signs of mental illness and perform basic tests of memory, concentration, etc. The medical workup is done to assess non-psychiatric needs, make sure they are addressed, and see if a physical problem might be causing or contributing to the psychiatric symptoms. After people stabilize they usually go back home. If they don't get better fast enough and are committed they go to the state hospital for long term inpatient care.

 

[whopper]

I go to the casino and use my psychiatry powers to psych out other people during poker and always leave the casino with at least $100K.
The mafia sometimes calls me up so while a guy's being interrogated, I can tell them just how much torture to apply to make them talk.
I convince people they are gay even when they are not. When they deny they are gay I tell them that since I'm a psychiatrist I know them better than themselves and the more the protest the more it just proves I touched upon a nerve proving they are gay.
I make fake LSD and sell it. When people tell me they didn't get high off of it, I tell them they didn't use it right. If they still tell me they didn't get a buzz I tell them "yeah well what really is a buzz?" If the cops ever come up o me I tell them I never really sold any LSD. I just like to collect paper with colorful dots on it. (Yes I stole this from Orange is the New Black).

BTW I'm just screwing with you.

But the gay thing I did once and it worked. It was way before I was a psychiatrist and was in college. A buddy of mine K (we were idiots, immature and 18 years old) starting picking on a guy on my floor (John) that he suspected was gay. Now K really was picking on John. He just wasn't doing some friendly ribbing and I suspected John guy really was gay so I was upset by K's homophobia and told him that I was convinced he was gay and he was really cruising for guys by pointing out homosexuals.

K got angry and I used the line "well this just proves I struck a nerve, you got to be gay." K instead of just blowing me off (not literally of course) went on further and further to prove he was not gay and I just pushed more and more that I'm more convinced he was gay. I started pulling in random thoughts like K just by coincidence was wearing red shorts. I told him that red was the color of Mars the god of war and a symbol of masculinity so it showed to me he wanted men around his private areas. The guy actually became freaked out and I then said "notice how no one here has red shorts" and literally no one on my floor had red shorts. This all of course was really just coincidence.

Then guys on my floor started hearing me talk to K and started laughing and entered my room (where we were) and started taking off their shirts while dancing in front of him. K felt uncomfortable. I told him "what exactly is making you uncomfortable? We're all fine here."

Well about 30 more minutes of this, K finally left my room, went to the communal shower area and all of the guys on the floor then jumped in the shower with him and all started talking effeminately, and did things like rubbed K's back and he ran out of the shower.

Now by this time I'm realizing this thing is going too far. Also we both had a major calculus exam at the next day and he's having a homosexual crisis but he's not homosexual. I go to the guy's room, apologize, and tell him he's not gay. I also gathered a collection of all the dirty magazines on the floor owned by the other guys on the floor and told him to look at them and reassure he's not gay. (This is before the Internet where most people now get their freak-on).

The next day the guy failed the exam. I felt really bad about that.

 

[turrgavi]

I go to the casino and use my psychiatry powers to psych out other people during poker and always leave the casino with at least $100K.
The mafia sometimes calls me up so while a guy's being interrogated, I can tell them just how much torture to apply to make them talk.
I convince people they are gay even when they are not. When they deny they are gay I tell them that since I'm a psychiatrist I know them better than themselves and the more the protest the more it just proves I touched upon a nerve proving they are gay.
I make fake LSD and sell it. When people tell me they didn't get high off of it, I tell them they didn't use it right. If they still tell me they didn't get a buzz I tell them "yeah well what really is a buzz?" If the cops ever come up o me I tell them I never really sold any LSD. I just like to collect paper with colorful dots on it. (Yes I stole this from Orange is the New Black).

BTW I'm just screwing with you.

But the gay thing I did once and it worked. It was way before I was a psychiatrist and was in college. A buddy of mine K (we were idiots, immature and 18 years old) starting picking on a guy on my floor (John) that he suspected was gay. Now K really was picking on John. He just wasn't doing some friendly ribbing and I suspected John guy really was gay so I was upset by K's homophobia and told him that I was convinced he was gay and he was really cruising for guys by pointing out homosexuals.

K got angry and I used the line "well this just proves I struck a nerve, you got to be gay." K instead of just blowing me off (not literally of course) went on further and further to prove he was not gay and I just pushed more and more that I'm more convinced he was gay. I started pulling in random thoughts like K just by coincidence was wearing red shorts. I told him that red was the color of Mars the god of war and a symbol of masculinity so it showed to me he wanted men around his private areas. The guy actually became freaked out and I then said "notice how no one here has red shorts" and literally no one on my floor had red shorts. This all of course was really just coincidence.

Then guys on my floor started hearing me talk to K and started laughing and entered my room (where we were) and started taking off their shirts while dancing in front of him. K felt uncomfortable. I told him "what exactly is making you uncomfortable? We're all fine here."

Well about 30 more minutes of this, K finally left my room, went to the communal shower area and all of the guys on the floor then jumped in the shower with him and all started talking effeminately, and did things like rubbed K's back and he ran out of the shower.

Now by this time I'm realizing this thing is going too far. Also we both had a major calculus exam at the next day and he's having a homosexual crisis but he's not homosexual. I go to the guy's room, apologize, and tell him he's not gay. I also gathered a collection of all the dirty magazines on the floor owned by the other guys on the floor and told him to look at them and reassure he's not gay. (This is before the Internet where most people now get their freak-on).

The next day the guy failed the exam. I felt really bad about that.

That is the most beautiful story I have ever had the pleasure of reading. Sorry K, but that memory is worth a little suffering. Thanks for taking one for the team!

*Decides to follow psychiatry*

 

[deleted407021]

Great story doc, lol!

How common is it for psychiatrists to practice psychotherapy, these days? Is there a primary care relationship with some patients?

 

[thoffen]

Common to do psychotherapy? Not really. However, common enough that you can easily get the training and do it. And there are certainly psychiatrists that function in a therapy-based practice, although you are limiting your income unless you do a blend of therapy & meds on your patients.

Primary care relationship? I'd say so. There are those that argue that psychiatrists should be doing a subset of primary care (esp. with antipsychotics driving people toward metabolic syndrome), and there are those that want to have clear delineation of roles, limitation of liability, and would only do it if reimbursed to do so. It's kinda up to you, but I will say despite my urging, some patients will really only have you as their doctor.

 

[deleted407021]

Common to do psychotherapy? Not really. However, common enough that you can easily get the training and do it. And there are certainly psychiatrists that function in a therapy-based practice, although you are limiting your income unless you do a blend of therapy & meds on your patients.

Primary care relationship? I'd say so. There are those that argue that psychiatrists should be doing a subset of primary care (esp. with antipsychotics driving people toward metabolic syndrome), and there are those that want to have clear delineation of roles, limitation of liability, and would only do it if reimbursed to do so. It's kinda up to you, but I will say despite my urging, some patients will really only have you as their doctor.

The idea of conducting therapy is very appealing, especially within the greater context of med management for both psych meds and chronic medical conditions. Being a psych/PCP/therapist is an intriguing combination. I'd imagine this setup is more reasonable in an underserved, maybe rural setting with fewer providers?

 

[heyjack70]

The idea of conducting therapy is very appealing, especially within the greater context of med management for both psych meds and chronic medical conditions. Being a psych/PCP/therapist is an intriguing combination. I'd imagine this setup is more reasonable in an underserved, maybe rural setting with fewer providers?

Probably more likely in an affluent metropolitan area, though you can do whatever you want in private practice. The demands on a psychiatrist to handle meds in a rural area, due to it being underserved, would push you away from therapy. No way any employer would pay you to do therapy in that setting.

 

[deleted407021]

Thanks, y'all. I hope this thread gets more responses, as I'm very interested.

 

[MacDonaldTriad]

Hay Whopper, Does K know about this? Probably the best answer to the glass houses and stones thing. Just ribbing you a bit.

 

[thoffen]

Hey don't hassel the Hoff!

 

[whopper]

For the newer people the above icon used to by my icon for SDN. I got rid of it cause my fellowship director told me my public face needs to be appropriate at all times (he is right). Well maybe that story isn't appropriate for the public face thing but heck I was 18 and I really was doing it to defend John.

John by the way wasn't gay and I later found out he was molested as a child. He was awkward in some ways and uncomfortable talking about sexual subjects. That's why I was offended that K. was picking on him.

The story actually is much more detailed and I could've written a chapter about it. At one point a mutual buddy of ours, Jeff, walked into my room and starting kissing K on the cheek and kept on saying, "K I'm just about an inch away from your lips. Just tell me to do it man and I'll do it cause I love you!"

Another guy on the floor-Mike was a body builder and for weeks K kept telling all of us how he wanted Mike's body. Of course he wanted his own body to be like Mike's, he literally didn't want Mike, but I used that as another gay spin. "K man you know you keep talking about Mike's body? Now I know why. Cause you're gay." Mike found out what was going on and walked in and started flexing his muscles in front of K telling him, "It's okay man. You can kiss my body if you want." While I stated, "notice how none of us really want his body? Only you do. Why is that?"

Also about 10 guys over the duration of this time were sneaking into the room just across the hallway cause they thought it was so funny and they wanted to eavesdrop on the entire thing. Other guys came into my room and Kedar kept renouncing he was gay and the other guys (on my cue) would respond, "don't worry K, whatever you are, I accept you. This is about accepting who you really are on the inside." The entire floor was literally laughing to the point where their bellies were hurting.

There's actually much more to the story and on other similar subjects.

 

[olivarynucleus]

My last interaction with a psychiatrist was very weird. I asked her if I could see my chart. I'm a med student so I know this is an option. She then changed the subject and started asking me sexual questions.

 

[Ceke2002]

The idea of conducting therapy is very appealing, especially within the greater context of med management for both psych meds and chronic medical conditions. Being a psych/PCP/therapist is an intriguing combination. I'd imagine this setup is more reasonable in an underserved, maybe rural setting with fewer providers?

Probably more likely in an affluent metropolitan area, though you can do whatever you want in private practice. The demands on a psychiatrist to handle meds in a rural area, due to it being underserved, would push you away from therapy. No way any employer would pay you to do therapy in that setting.

Depends on where you live I guess, whether or not it's a service for the affluent or the underserved. The CMHC that my Psychiatrist works at is in an underserved, lower socio-economic region, and he is still able to provide psychotherapy, med management and some primary health care services to his patients at that clinic. Mind you I have noticed he does seem a lot more relaxed at the other clinic I see him at now, where his primary role is as a Psychotherapist and he doesn't seem to be walking around like he's going to punch the next Government suit that walks through the door and tries to tell him how to do his job.

 

[Ceke2002]

For the newer people the above icon used to by my icon for SDN. I got rid of it cause my fellowship director told me my public face needs to be appropriate at all times (he is right). Well maybe that story isn't appropriate for the public face thing but heck I was 18 and I really was doing it to defend John.

John by the way wasn't gay and I later found out he was molested as a child. He was awkward in some ways and uncomfortable talking about sexual subjects. That's why I was offended that K. was picking on him.

The story actually is much more detailed and I could've written a chapter about it. At one point a mutual buddy of ours, Jeff, walked into my room and starting kissing K on the cheek and kept on saying, "K I'm just about an inch away from your lips. Just tell me to do it man and I'll do it cause I love you!"

Another guy on the floor-Mike was a body builder and for weeks K kept telling all of us how he wanted Mike's body. Of course he wanted his own body to be like Mike's, he literally didn't want Mike, but I used that as another gay spin. "K man you know you keep talking about Mike's body? Now I know why. Cause you're gay." Mike found out what was going on and walked in and started flexing his muscles in front of K telling him, "It's okay man. You can kiss my body if you want." While I stated, "notice how none of us really want his body? Only you do. Why is that?"

Also about 10 guys over the duration of this time were sneaking into the room just across the hallway cause they thought it was so funny and they wanted to eavesdrop on the entire thing. Other guys came into my room and Kedar kept renouncing he was gay and the other guys (on my cue) would respond, "don't worry K, whatever you are, I accept you. This is about accepting who you really are on the inside." The entire floor was literally laughing to the point where their bellies were hurting.

There's actually much more to the story and on other similar subjects.

In regards to K, some people shouldn't dish it if they can't take it, and to pick on an apparent easy target like John is an act of sheer cowardice. He got what was coming to him.

 

[whopper]

Well that's what all my friends told me. It was by coincidence but everything K and I did were parallel. E.g. we were both pre-med, had to take many of the same classes, and fate just had it bad for him.

E.g. he always got the 8 AM classes and I always ended up getting the choicier afternoon classes. (Better cause in our dorm you could not go to sleep before midnight even if you wanted to because everyone was partying, and for whatever reason those afternoon classes seemed to have TAs that were more lenient with the grading).

I had a little strategy (and remember this was before the age of the Internet), you had to register at Syracuse U by going into a line that was literally 10 blocks long, wait in line about 5 hours and then you finally sat with someone that got you into your classes. This process was open about a month.

K had to wait in line about 5 hours a day and kept getting the 8 AM classes, then would go into the line the next day to try to get changed to the afternoon classes-another 5 hours. Probably spent about 80 hours over the course of a month and couldn't get any of the better classes.

So I told him, my strategy was to go into the line the very last day at the last 15 minutes. I told him I knew all of the classes would be filled up by then so they would have to override the computer system to let me in. When they asked me which one to be in I'd tell them to put me in the afternoon class cause I figured the computer geek doing the schedule would've seen thousands of people by then and would've been too nonchalant about pushing people into the morning class.

K kept proclaiming I was a fool. I told him to do my strategy. I meant it. I told him how could a university not let a guy complete is own freaking major? They had to let me in. Worst case scenario they put me in the 8 AM class that I would've been in anyway had I done what K was doing. I told him to do what I was doing.

So here I was---the very last day to register, the last 15 minutes, and now the lines are all non-existent. I didn't have to wait one minute. I sit down, and it happened exactly as I thought it would. They told me all the classes were filled but they knew I was pre-med and had to get into those classes for my sophomore year and they over-rode me into every class I wanted. I was out of there in less than 10 minutes and got the exact schedule I wanted.

So I come back to the dorm, and I'm holding my schedule in my hand in the air, and first thing when the elevator opens is K and he's telling me "I know you got a screwed up schedule, " and I showed it to him. His face turned red with anger, and he started telling people how I just make fun of him all the time and it was my role in life to belittle him. A few days later he's then telling people how I intentionally misled him into waiting in the lines and he got screwed and if I were a true friend I would've told him my strategy.

Thing was that everyone on the floor heard me out in the open tell my strategy and invite him to join him which caused people to think something was wrong with K and think I was the wiley-party guy to be cool to hang with that is lucky all the time.

And this just made K hate me more and more.

There's a lot more to the story but I'll just end it one last one this cause each story ended pretty much the same.

There was a football pool on our floor. I noticed each time K played he lost. So after 4 weeks of seeing him lose each time as a joke to myself I told myself I'll bet on the opposite team K bet on.

So I won about 5 straight weeks. In fact people started thinking I had some type of system. I used to be a computer hacker and everyone knew I was a geek (read comics, into science, wouldn't miss an episode of Star Trek TNG that was still on it's first run on TV) so all the jocks thought I was some guy the mafia would've hired if I didn't go to college to fix the books. I hardly knew anything about football. I never followed football except for the play-offs. So K asked me at lunch (with everyone on the floor sitting there) what was my system. I told him what it was.

"K-man, here's what I do. I find out what team you bet on and I bet on the opposite team."

His face was aghast. In that particular case for real I could see why someone would be upset with me because I should've been more diplomatic and this was in a public forum. As for the football pool, from that day on he refused to let anyone know who he bet on so I couldn't use my system anymore.

What happened was for the rest of the year stuff like this happened despite that I really had no intended agenda against K. He really hated me after first year. There are more stories along these lines but they all ended the same way. With me ahead, no one thinking I did anything wrong, everyone thinking K should loosen up and him hating me as if I was sent to Earth to curse him.

A few times as a sophomore I was actually feeling real bad about what happened, talked to a mutual friend about it, and that friend pulled out a tape of K arguing where he's denying things that happened just minutes before "I never said that" Then later the friend pulls out a recording of K saying what he just denied and K replied "Man that is the biggest sign of disrespect that you can't believe me so you have to tape me."

This is a big example of someone that had a lot of pathological defense mechanisms. This is a guy that wouldn't have benefited from meds and needed some serious cognitive and rational-emotive therapy.

 

[whopper]

I'm going to answer the original question instead of telling stories of K.

What's it like? It varies per setting. Whether it's ER, inpatient-voluntary or involuntary, office, forensic, what have you.

ER and inpatient really aren't much different from IM except that you're dealing with serious mental illness that follow disease models more similarly to that of IM in the sense that the theories behind these pathologies are more grounded in biochemical and physiological stuff (e.g. bipolar disorder, schizophrenia, severe depression), the other stuff usually doesn't need hospitalization. You need to be on top of their labs and watch out for physical problems with the patient's body much more than outpatient cause many of them have poor self care or survived a suicide attempt.

Outpatient ranges from medication management to very in-depth psychotherapy.

Some factors about psychiatry that I think makes it different vs other fields of medicine are usually no procedures though ECT or TMS could be considered that. Your hours very very flexible. You can pick the hours you want. Your patient base is usually less appreciative. People on inpatient usually are on the bottom dredges and you often do the opposite of what they want such as involuntarily commit someone psychotic and homicidal, so when you get them better they're usually not buying you a cake. A GI colleague of mine at X-Mas is littered with gifts. I usually don't get any. The gifts don't really matter but what does make a difference is the bond you have with your patients in which case it is more affirming to have patients with good insight that appreciate what you do. In inpatient this doesn't happen much if at all. In outpatient it happens less vs other fields.

Another separating factor is the patient's emotional problems could burden yourself. It's important to make sure your counter-transference is held in check.

You'll also get a larger load of emotionally tolling patients in outpatient vs other fields. Not surprising. This is psychiatry. Many of them try to transfer their angst onto you.

 

[Gambler 101]

Would it be possible to practice mostly women's mental health and provide primary care services? How much can you do without an OB/GYN residency? Would it be better to do both residencies?

 

[notdeadyet]

Would it be possible to practice mostly women's mental health and provide primary care services? How much can you do without an OB/GYN residency? Would it be better to do both residencies?

No, you need to do a residency and focus on an area of expertise:

Family Practice- You can provide primary care services for women up to and including childbirth. You can also handle very rudimentary depression and anxiety, but not function as a psychiatrist.
OB/GYN- you can provide a full spectrum of women's health services. You could also theoretically handle rudimentary depression and anxiety, but in the interactions I've had, they tend to punt to psych pretty quickly when they are able to do so.
Psychiatry- you can provide a full spectrum of mental health services, and with the right residency and adequate training, you can become an expert in women's mental health. You will not be providing primary care services as a psychiatrist.

Doing both residencies is complicated due to funding issues. It would also potentially drive you mad. When folks do two residencies (or even two fellowships), it tends to be "holy $hit, I can't believe I did ____" and jump ship. Very few people intentionally do two complete residencies and very, very few maintain and practice in both.

If you are still considering doing it, you can do an abbreviated psychiatry and family practice combined residency in 5 years, if they are still left by the time you reach residency (they've been dwindling).

But you have plenty of time. It is completely level-appropriate to want to do it all. When you trudge through medical school, you start to see what you REALLY like and where to focus. Having too many interests when you start is a much better animal than being two specific ("I'm going to be the best cardiothoracic surgeon in the South East!!!"). The latter folks are the ones who are most likely to get crushed when they go through medical school ("Oh, wow, I don't actually like surgery....").

 

[Gambler 101]

No, you need to do a residency and focus on an area of expertise:

Family Practice- You can provide primary care services for women up to and including childbirth. You can also handle very rudimentary depression and anxiety, but not function as a psychiatrist.
OB/GYN- you can provide a full spectrum of women's health services. You could also theoretically handle rudimentary depression and anxiety, but in the interactions I've had, they tend to punt to psych pretty quickly when they are able to do so.
Psychiatry- you can provide a full spectrum of mental health services, and with the right residency and adequate training, you can become an expert in women's mental health. You will not be providing primary care services as a psychiatrist.

Doing both residencies is complicated due to funding issues. It would also potentially drive you mad. When folks do two residencies (or even two fellowships), it tends to be "holy $hit, I can't believe I did ____" and jump ship. Very few people intentionally do two complete residencies and very, very few maintain and practice in both.

If you are still considering doing it, you can do an abbreviated psychiatry and family practice combined residency in 5 years, if they are still left by the time you reach residency (they've been dwindling).

But you have plenty of time. It is completely level-appropriate to want to do it all. When you trudge through medical school, you start to see what you REALLY like and where to focus. Having too many interests when you start is a much better animal than being two specific ("I'm going to be the best cardiothoracic surgeon in the South East!!!"). The latter folks are the ones who are most likely to get crushed when they go through medical school ("Oh, wow, I don't actually like surgery....").

Thanks for the clarification! I've had OB/Gyn and Psych rotations. I liked them both and would love to take care of the entire person. I noticed most of the psych patients have limited resources and often lack medical primary care. I'll think some more about my decision. Thanks!

 

[notdeadyet]

No worries. And you don't really have to make any kind of decision until medical school. Who knows what you'll fall in love with once you get exposure to it all. Psychiatry was certainly nowhere NEAR my radar when I started the medical school path.

 

[nexus73]

From my perspective, you should pick one specialty or the other. I think the goal of wanting to take care of the entire person is admirable, but the intellectual ability necessary to do this well is far beyond the capacity of the vast majority of individuals. You will not only have to be extremely gifted to become competent in both OBGYN and psych, you will have to maintain diligent efforts to stay on top of best practices in two very separate fields over time. I think a physician could do both and be 'okay' at it, but to really be masterful a single focus would serve you better. Psychiatry is hard enough on its own.

Ultimately, if you do a combined FM/Psych residency with the goal of delivering babies plus providing psychiatric care, I suspect that over time you will gravitate towards a psych only focus because it is going to pay better and have fewer headaches than primary care plus OB. In talking with others who have retrained in psychiatry from primary care, no one continues to do primary care afterwards.