What's challenging about a psych residency?

[l0st1]

Good morning, I have been trying to decide between IM and psych, and after exhausting my list of pros & cons, one if the last considerations I have is finding my daily work challenging as without a challenge, I tend to lose motivation. When I envision myself in a psych residency, I imagine relatively lax hours and layed back days (outside of the intern months). In fact my only concern is getting along with the other residents and hoping that I'm not stuck with anybody annoyingly neurotic for 4 years.

On the other hand, I think simply juggling the high workload in IM will be a challenge and the prospect of having to maintain good bedside manner amidst the chaos is exciting to me as well.

I realize that this may not be a realistic view of either residency so I'd like to ask your views about the challenges that keep you going during your psychiatry residency.

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[slappy]

Why do you want to do a psychiatry residency?

 

[Shikima]

Why not do a combined program?

 

[Dharma]

You don't think there will be "annoyingly neurotic" folks on your IM service?

What's your gut factor? Sounds like you find yourself stuck at a crossroads but I'm gathering deep down you know which way to go.

 

[OldPsychDoc]

Two words: diabetic feet.

 

[Mad Jack]

You don't think there will be "annoyingly neurotic" folks on your IM service?

What's your gut factor? Sounds like you find yourself stuck at a crossroads but I'm gathering deep down you know which way to go.

And at least with psych, you're not dealing with the "annoyingly neurotic" for 80 hours a week, every week, for three years...

 

[675015]

There's more to a challenge than how hard you work.

As for the bedside manner comment... Try working in the ER (or even an active inpatient or CL service) where it seems like one patient is trying to piss you off, one seens like they are trying to make you laugh, one is genuinely suicidal, and one is psychotic. There is certainly a challenge to maintain good bedside manner in this environment and the internists and ER docs EXPECT it from the psychiatrists because they know they won't be able to do it.

Side note, an attending in this forum (sorry forgot who) recently posted a story of a fight he broke up in his waiting room. Try doing that while maintains bedside manner for the rest of your patients watching!

 

[MacDonaldTriad]

Two words: diabetic feet.

So ER medicine, two words “butt puss”
IM two words, “diabetic feet”
I wonder what it should be for psychiatry? “I’m suicidal” (but said while smiling).

 

[Bartelby]

Things I have found challenging and that I enjoy about psychiatry...

We know a lot, but we don't know a lot. You can memorize treatment algorithms but the lack of firm pathophysiologically based diagnoses means that there is a lot to sort through based on your experience, reading and critical thought. Being able to carefully tease out subtle psychosis, delirium that others think is an affective disorder, somatic delusions, etc etc takes a lot of experience and can save patients months or years of suffering with incorrect diagnoses or treatment, or can avoid "throwing everything" at the person in hopes that you find a treatment that will work. This is a lot different than pulling out a DSM and running through a checklist, and it is very rewarding when you are right about a tough call.

In long term treatment, especially psychotherapy, again things become philosophical and critical thought comes into play. Is the patient's new symptom best conceptualized as a manifestation of disease requiring changes in pharmacological or other biological treatments? Is it a result of social stress, intrapsychic conflict, a transference reaction to you, a side effect of a medication (even the ones being used to treat the original problem)? Again you will be hard pressed to find an algorithm that walks you through quality evaluation and management because it becomes somewhat fuzzy, but coming to a decision based on your experience and thought is critical for appropriate treatment.

You will deal with volatile and emotionally charged situations on a regular basis (especially on inpatient or consult) and learning how to work within systems and redirect bad situations in such a way that the right thing happens for the patient is a difficult but potentially very rewarding feat.

You get to read a large number of theoretical perspectives (biological, psychodynamic, psychoanalytic, CBT, ACT, DBT, on and on) and you have to put it all into context to become the best clinician you can be, integrating and judging the material with a critical mind. This is challenging and extremely interesting for treatment and for your larger understanding of how people work as a whole!

Also for me the challenge of working very long, high-stress hours in marathon fashion is not one I particularly enjoy. Being honest with yourself about this now can save you grief later, whichever way you answer.

I may chime in with more later, just a few that come to mind off the top of my head.


One caveat: I reference not following algorithms but this is not a jab at IM. IM is an extremely difficult speciality for which I have the utmost respect.

 

[wolfvgang22]

I think the original poster could be grossly underestimating how challenging psychiatry CAN be in residency. I know that for me, residency was a LOT more of a challenge and responsibility than the cushy psychiatry rotations I had in med school. As I student, I never had 10 new inpatient psychiatric admissions of severely ill patients in one night on call, with 4 patients in restraints. I certainly did as a resident! I was on call every third night in a busy psych for the first two years. Code blues, while not frequent, did happen. Seizures, self harm, agitation are not infrequent in inpatient psychiatry. Also, don't underestimate how intellectually challenging and emotionally draining it can be to work with the seriously mentally ill every single day. I love it.

However, if you want to "be a real doctor" and you think psychiatry isn't that, by all means go into IM.

 

[smalltownpsych]

Good morning, I have been trying to decide between IM and psych, and after exhausting my list of pros & cons, one if the last considerations I have is finding my daily work challenging as without a challenge, I tend to lose motivation. When I envision myself in a psych residency, I imagine relatively lax hours and layed back days (outside of the intern months). In fact my only concern is getting along with the other residents and hoping that I'm not stuck with anybody annoyingly neurotic for 4 years.

On the other hand, I think simply juggling the high workload in IM will be a challenge and the prospect of having to maintain good bedside manner amidst the chaos is exciting to me as well.

I realize that this may not be a realistic view of either residency so I'd like to ask your views about the challenges that keep you going during your psychiatry residency.

My avatar expresses how I feel about saying that psych isn't challenging.

 

[OldPsychDoc]

So ER medicine, two words “butt puss”
IM two words, “diabetic feet”
I wonder what it should be for psychiatry? “I’m suicidal” (but said while smiling).

"My Xanax"

 

[so721]

on rotations for Psych or with psych pts, Most challenging for me, is to care too much about some of the young kids who throw away their lives due to substances, bad childhoods, etc.

I think I see my daughter in some of them sometimes and I feel extra heartache, as I imagine that it could be one of my kids easily who decides to become an addict and then becomes suicidal. I need to stop this though before residency.

PS... im not a resident, but going to be come july

 

[OldPsychDoc]

on rotations for Psych or with psych pts, Most challenging for me, is to care too much about some of the young kids who throw away their lives due to substances, bad childhoods, etc.

I think I see my daughter in some of them sometimes and I feel extra heartache, as I imagine that it could be one of my kids easily who decides to become an addict and then becomes suicidal. I need to stop this though before residency.

No you don't. It never stops--not if you still have a couple of shreds of humanity left. You just need to be aware that you are feeling that and why.

 

[Leo Aquarius]

To answer the OP's question:

The guilt that comes from watching your IM and surgery colleagues staying very late while you go home on time.

 

[michaelrack]

Psychiatry residency is challenging if you are trying to become an excellent psychiatrist who can utilize multiple treatment modalities (including several psychotherapies) and competently assess a patient. It can be pretty easy if you just go through the motions.

 

[l0st1]

Why do you want to do a psychiatry residency?

You don't think there will be "annoyingly neurotic" folks on your IM service?

What's your gut factor? Sounds like you find yourself stuck at a crossroads but I'm gathering deep down you know which way to go.

Thanks for asking the right questions. The biggest drawing factor for me is the lifestyle. I have a family and my wife is a surgery resident. I appreciate that I would have more control over my schedule and work as little or as much as I see fit upon graduating from residency.

The second factor that brought me closer toward psych is that a family member has a history of mental disease, which has long been at the core of my family, and I've been closely involved with his treatment and outcomes. A large part of my personal statement concerns of this issue, the incidents surrounding it and how it has affected me.

Finally, I enjoy the humanities more than the hard sciences. At times while knee deep in medical topics or during rounds, I've asked myself "what's the point in learning all of this medicine? I will finally be comfortable with the knowledge and will have the treatment guidelines memorized, but so what? I could have just as well Googled them on my phone". I feel that perhaps I don't inherently enjoy medicine enough to embark on life-long learning of it and would rather pursue learning in other areas such as philosophy, history and literature. It's almost as if I have become jaded by the actual practice of hospital medicine. Having said that, I have also met IM physicians and surgeons who are very well versed in these topics and others outside of medicine. I can only assume that either they possess superior time management skills than I or that I am wrong about the nature of a career in IM and its sub-specialties.

I have a great facility in reading social situations, personal cues and communication, which has served me well in my rotations and in life in general. While I have been told and this will be useful in psychiatry, I worry that quite the opposite may be true and that the average psych patient will not appreciate my social skills as much as the average sick patient on the IM floor would.

 

[l0st1]

Another persistent question on my mind has been "Am I leaning toward psychiatry simply because I no longer enjoy the rest of medicine? Because I'm tired or to some degree burnt out after my third year of medschool?"

 

[Dharma]

@l0st1 what's the gun-to-the-head decision? First one that pops into your head? Why is that the answer? You cool with that answer? What bothers you about it?

No need to answer here; just wanted throw some food for thought your way, not that I know much.

And BTW if psychiatry gives you "the tingles" (in a good way) I say go with it and don't look back brother!

 

[Leo Aquarius]

What do you want to achieve as a physician? Answer this and you can better navigate your dilemma.

 

[milesed]

In residency, the workload for IM was the same or less than psyc rotations. On call for psyc was much busier, but now it is probably easier than IM docs after residency- it is what you set either up to be.

 

[Leo Aquarius]

In residency, the workload for IM was the same or less than psyc rotations. On call for psyc was much busier, but now it is probably easier than IM docs after residency- it is what you set either up to be.

You must have either had an insane psychiatry program or a lazy IM program. Are you in the USA?

 

[Ψ-117]

Good morning, I have been trying to decide between IM and psych, and after exhausting my list of pros & cons, one if the last considerations I have is finding my daily work challenging as without a challenge, I tend to lose motivation. When I envision myself in a psych residency, I imagine relatively lax hours and layed back days (outside of the intern months). In fact my only concern is getting along with the other residents and hoping that I'm not stuck with anybody annoyingly neurotic for 4 years.

On the other hand, I think simply juggling the high workload in IM will be a challenge and the prospect of having to maintain good bedside manner amidst the chaos is exciting to me as well.

I realize that this may not be a realistic view of either residency so I'd like to ask your views about the challenges that keep you going during your psychiatry residency.

One of the challenges of psychiatry is, of course, working with a patient population that no one else wants to deal with. I always find it funny when I go to see a patient on a consult, and before I go into the room, the nurse asks "Who are you with?" and when I tell them I'm with Psychiatry, they say "Oh, thank you!" and are immediately relieved as if I'm some kind of superhero there to save the day.

Psychiatrists are called upon to manage severe behavioral problems. You deal with patients who are angry, yelling, and violent. Not uncommonly, on the inpatient unit, I would be interrupted during an interview with a patient to go manage someone who was attacking another patient, banging incessantly on the nursing station window, or throwing furniture around. You may receive demented patients who are dumped at the hospital by their nursing home, who will no longer accept the patient back because they attacked a nurse, and now you've got to figure out a way to discharge them once they're better. In clinic, a frequent challenge is dealing with patients who always seem to be in crisis every time they come see you. (Is there a code for Chronic Crisis Disorder?) Or getting referred a patient by their PCP to manage their anxiety, who started them on benzos as a first-line treatment two years ago thinking it was a good idea and sent them to you to get them off benzos. And of course, one of the challenges I've come to accept, is that you always need to have a plan for what you're going to do at the patient's next visit, anticipating that the treatment you recommend today isn't going to work.

 

[Frazier]

You must have either had an insane psychiatry program or a lazy IM program. Are you in the USA?

Curious as well...must be institution dependent. I'm on IM clerkship and these folks are here constantly and always "on".

 

[milesed]

You must have either had an insane psychiatry program or a lazy IM program. Are you in the USA?

Yes, US residency from 1996-2000. No, it was typical for both. The IM was at a VAMC and we did exactly what other IM residents did. Psyc was harder as we covered ER call for a "county" ER and the Medical Univ ER. You can't learn much if you are not busy.

 

[Psychobabbling]

I always find it funny when I go to see a patient on a consult, and before I go into the room, the nurse asks "Who are you with?" and when I tell them I'm with Psychiatry, they say "Oh, thank you!" and are immediately relieved as if I'm some kind of superhero there to save the day.

Taken further, this also shows how much we are devalued.

"Oh, that patient broke into the sharps container? Call psychiatry." - WHAT? CALL THE POLICE

"Patient brought to the psyc ER for trespassing for the past week, going into people's yards at night and peering into their windows, checking if doors are locked, etc." - ARREST HIM. THIS IS ILLEGAL. Talking to the cop "well doctor, just so you know, he's been doing that for the past week, he also assaulted someone at a bus stop." "Well, officer, just so you know, he does not exhibit any acute psychiatric issues at this time that warrant inpatient hospitalization. Also, you've been allowing someone to continue to break the law for the past week. Any questions?"

"Psyc consult - patient was on Lexapro 10 years ago. Has been off for 9 years. ? if patient needs meds now, not currently depressed."

"Psyc consult - patient was 'agitated,' screamed at nurse." What happened, to the patient who can barely move, secondary to advanced parkinson's 'I told them my hip hurts and they keep moving me" (pt had a hip fracture.....)

"Psyc consult - patient was upset that the temperature in their room was not to their liking, demanded higher dose of opiate, threatened suicide if demands weren't met. We met demands. Pt denied SI and said "thank you." This happened 3 days ago. Consult for SI."

"Psyc consult for competency to tell us if this person will take his insulin when he is discharged" - (a) not competency (b) can't predict the future. "But, the patient said he needs help to take it if he goes home, so you need to tell us now." - No, you need to get them more services/home aide/etc.

 

[MacDonaldTriad]

"Patient brought to the psyc ER for trespassing for the past week, going into people's yards at night and peering into their windows, checking if doors are locked, etc." - ARREST HIM. THIS IS ILLEGAL. Talking to the cop "well doctor, just so you know, he's been doing that for the past week, he also assaulted someone at a bus stop." "Well, officer, just so you know, he does not exhibit any acute psychiatric issues at this time that warrant inpatient hospitalization. Also, you've been allowing someone to continue to break the law for the past week. Any questions?"

Of course the flip side to this coin exists if you are a psychiatrist working at a jail.

“Officer, why do you keep charging these acutely psychotic schizophrenic patients with trespassing and putting them in jail? They should be in a hospital.”

 

[Shikima]

It's both. There needs a better screening and education process than utilizing psychiatrists as social workers.

 

[OldPsychDoc]

Of course the flip side to this coin exists if you are a psychiatrist working at a jail.

“Officer, why do you keep charging these acutely psychotic schizophrenic patients with trespassing and putting them in jail? They should be in a hospital.”

And then the sheriffs go to the state legislature and get a law passed such that any jail inmate with a mental health diagnosis MUST be admitted to a mental health unit within 48 hours, thus flooding the system and backing up non-criminal psychiatric patients in our ERs...and on it goes.

 

[Psychobabbling]

Of course the flip side to this coin exists if you are a psychiatrist working at a jail.

“Officer, why do you keep charging these acutely psychotic schizophrenic patients with trespassing and putting them in jail? They should be in a hospital.”

Except when they're not psychotic, but a lotta antisocial

 

[MacDonaldTriad]

Seems like there are a lot of people who are alarmed at their one view of the elephant named mental health system, and they pass a lot of laws to “fix it”. No wonder we end up in places no one wants us to be. -> -> ->

 

[Shikima]

And then the sheriffs go to the state legislature and get a law passed such that any jail inmate with a mental health diagnosis MUST be admitted to a mental health unit within 48 hours, thus flooding the system and backing up non-criminal psychiatric patients in our ERs...and on it goes.

It's because of a lack of training and education on their part to manage people and the staffing (due to being poorly funded and a shortage of MH workers) causes the expensive revolving door syndrome. Not only do you have a cost for booking/jail, but then for the ER and ?hospitalization. Hiring of forensic psychiatrists and having forensically trained SW would stop a lot of this through comprehensive evaluations with the mandate that is based on accurate and empiric diagnostic criterion.

 

[smalltownpsych]

It's because of a lack of training and education on their part to manage people and the staffing (due to being poorly funded and a shortage of MH workers) causes the expensive revolving door syndrome. Not only do you have a cost for booking/jail, but then for the ER and ?hospitalization. Hiring of forensic psychiatrists and having forensically trained SW would stop a lot of this through comprehensive evaluations with the mandate that is based on accurate and empiric diagnostic criterion.

Another part of the problem is that the system gets taxed by the substance abusers who are "working it". "I can't stop using meth and get a job because i am depressed." I used to spend about an hour or two a day at a local county jail and it was amazing how these "severely depressed" inmates would bounce right back when they were in the pod, laughing and playing cards with friends, and didn't know I could see them. I didn't see recoveries like that with severely depressed people on inpatient units. We waste way too much of our resources dealing with these patients and too many people in our system fall for it.

 

[Bartelby]

Another part of the problem is that the system gets taxed by the substance abusers who are "working it". "I can't stop using meth and get a job because i am depressed." I used to spend about an hour or two a day at a local county jail and it was amazing how these "severely depressed" inmates would bounce right back when they were in the pod, laughing and playing cards with friends, and didn't know I could see them. I didn't see recoveries like that with severely depressed people on inpatient units. We waste way too much of our resources dealing with these patients and too many people in our system fall for it.

An excellent point, though I don't think most people are "falling for it." They are just following self-interest.

If the substance abuser who has been using the inpatient unit like a revolving door comes in again saying he is depressed, this time he's really going to do it, he was standing on the bridge before his friend called and convinced him to come in, but you know with rock-solid collateral that there is a 90% chance the guy is malingering it is still an incredibly tough decision to discharge him. If you admit him, you tap out a quick note (can be brief because you are admitting for expressed suicidal ideation with plan and intent), place him on an involuntary hold and start a bed search. He goes inpatient for four days. Done. If you choose not to, you have to gather more collateral, write a more extensive note showing your reasoning (which better be spelled out in detail), and then take the risk that if he does happen to kill himself (even if it's a gesture) you will be the one who discharged him from the ER. Sometimes you even have to get security to escort these people out because they just will not leave, and how would that look to a jury? Can you really convince a jury of non-medical "peers" that you made the right call to force out someone who in fact killed themselves *right after* they told you that was just what they were going to do?

So all the incentives line up to just hospitalize. Sure, the insurance company can "take the chance" on calling their bluff, because thanks to ERISA they are immune to a suit for any value more than what the care would have cost! Basically the game is rigged, and it's hard to expect psychiatrists to put themselves at such a huge personal liability just to save the system a few dollars, so the cycle continues. Honestly I think we need specific legislation protecting from suit in these circumstances, that might curb the problem.

 

[OldPsychDoc]

...Hiring of forensic psychiatrists and having forensically trained SW would stop a lot of this through comprehensive evaluations with the mandate that is based on accurate and empiric diagnostic criterion.

Because there's just thousands of those milling around in unemployment lines right now, right?

 

[Shikima]

Because there's just thousands of those milling around in unemployment lines right now, right?

I did say there is a shortage of MH workers. And I also believe the system is created for psychiatrists to squander their education leading to a shortage of resources... However, it only takes a good forensic psychiatrists who is managing a team of SW to assess people for malingering as previously noted.

 

[smalltownpsych]

An excellent point, though I don't think most people are "falling for it." They are just following self-interest.

If the substance abuser who has been using the inpatient unit like a revolving door comes in again saying he is depressed, this time he's really going to do it, he was standing on the bridge before his friend called and convinced him to come in, but you know with rock-solid collateral that there is a 90% chance the guy is malingering it is still an incredibly tough decision to discharge him. If you admit him, you tap out a quick note (can be brief because you are admitting for expressed suicidal ideation with plan and intent), place him on an involuntary hold and start a bed search. He goes inpatient for four days. Done. If you choose not to, you have to gather more collateral, write a more extensive note showing your reasoning (which better be spelled out in detail), and then take the risk that if he does happen to kill himself (even if it's a gesture) you will be the one who discharged him from the ER. Sometimes you even have to get security to escort these people out because they just will not leave, and how would that look to a jury? Can you really convince a jury of non-medical "peers" that you made the right call to force out someone who in fact killed themselves *right after* they told you that was just what they were going to do?

So all the incentives line up to just hospitalize. Sure, the insurance company can "take the chance" on calling their bluff, because thanks to ERISA they are immune to a suit for any value more than what the care would have cost! Basically the game is rigged, and it's hard to expect psychiatrists to put themselves at such a huge personal liability just to save the system a few dollars, so the cycle continues. Honestly I think we need specific legislation protecting from suit in these circumstances, that might curb the problem.

If the suicidal patient tests positive for substances, they need substance abuse treatment more than standard inpatient treatment. They also don't need benzos (except for DTs, of course) and something to help them sleep and when they want to leave the next day, we should be able to let them go without fear of liability. I have argued on this board here before that substance abuse is different from other mental health issues and needs to be treated as such, but infortunately too many of us buy into the "they are self-medicating their underlying disorder" line.

 

[OldPsychDoc]

If the suicidal patient tests positive for substances, they need substance abuse treatment more than standard inpatient treatment. They also don't need benzos (except for DTs, of course) and something to help them sleep and when they want to leave the next day, we should be able to let them go without fear of liability. I have argued on this board here before that substance abuse is different from other mental health issues and needs to be treated as such, but infortunately too many of us buy into the "they are self-medicating their underlying disorder" line.

This is why we TALK to patients and TAKE HISTORIES and GET COLATERAL. If by the end of residency you aren't able to distinguish between depression due to the direct effects of a substance vs. sadness about the consequences of addiction vs. a primary mental health disorder contributing to the development and maintenance of addiction, then you really haven't learned anything about addiction.

Please don't glibly dismiss the dual diagnosis patient as a "line" just because the psych symptoms come along with a positive urine screen. You're smarter than that.

 

[smalltownpsych]

This is why we TALK to patients and TAKE HISTORIES and GET COLATERAL. If by the end of residency you aren't able to distinguish between depression due to the direct effects of a substance vs. sadness about the consequences of addiction vs. a primary mental health disorder contributing to the development and maintenance of addiction, then you really haven't learned anything about addiction.

Please don't glibly dismiss the dual diagnosis patient as a "line" just because the psych symptoms come along with a positive urine screen. You're smarter than that.

I am not dismissing the dual diagnosis patient. Unfortunately, many of the mental health professionals that I have worked with in the past tend to see all people with addiction as dual diagnosed and have a belief that addiction is caused by underlying, untreated mental illness. I work with people with addiction all the time and when I am treating their co-morbid condition, I am very careful to dash this reason to relapse. I am sure that you have all heard it before, "Maybe the reason I used was because of X disorder and now that I am getting better from X, I can probably still drink." It ranks right up there with "I never really had much of a problem with this drug so I can probably still use it." Addicts need help sorting out the lies they tell themselves and too many of us fall into the trap of supporting this. That's why I referred to it as a line. Oh, and I actually think it might be better to take the perspective that distinguishing between the factors you mentioned is often an impossible call, initially, and usually requires substantial time away from substances for the truth to really be known. It's just another thing that makes this field so challenging.