When's the best time for psych rotation? & other qs

[235750]

We are picking our 3rd and 4th year schedules already and I must decide the sequence of my clerkships. As a non-trad I am 100% sure that I want to be a psychiatrist so knowing this, is it best to have psych be my first rotation or the last?

Personally I would like to get surgery & general surgery done with just to have it out the the way. As they would be my 1st rotations I'm expected to be an imbecile, so they would have to cut me some slack, right? Also, I figure if I can get psych to be my last 3rd year rotation I won't be a complete idiot by then and might even know something. What do you think about that? IM, the other important rotation for psych I'm told, would be halfway in the year

My school does a poor job of explaining things, and I was hoping you all might be able to help with some of the terminology of clinical education. What's an elective vs. a sub-I (or is it sub-1??) vs a selective? I found a thread made several years ago where billypilgrim37 asked this same question, but I didn't see an answer. In our 4th year we are required to do an "amb surgical sub-1 selective" as well as "medical sub-1" but I have no idea what these mean.

I am already lining up a 4th year elective psychiatry rotation (or sub-1 or whatever). I have ties to the military and am looking at an inpatient unit that deals with mostly PTSD and suicides. Is that ok? What should I be looking for when picking these 4th year rotations? Should the psych rotations always be inpatient for example?

What other non-psych electives should I do?

FYI: I'm a DO student looking to match somewhere non-competitive in the years to come.

Thank you as always for your help.

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[notdeadyet]

We are picking our 3rd and 4th year schedules already and I must decide the sequence of my clerkships. As a non-trad I am 100% sure that I want to be a psychiatrist so knowing this, is it best to have psych be my first rotation or the last?

Neither. Talk to your school upperclassmen that you know. Everyone has their own ideas about the sequence of third year clerkships, but at the end of the day, it doesn't make as much difference as you might think.

That said, I wouldn't do my most likely residency's clerkship first or last. You will not be at your best at your first rotation, as you'll be still learning the EMR, how to do H&Ps, how to write notes, and how to interact with patients and staff. Folks tend to do worse on their shelves and honors are harder to come by. You also probably don't want it as one of your final rotations. If you work hard on every rotation (and not everyone does), by the time you get to your last rotation, you can be pretty burnt.

The sweet spot in most people's minds tends to be around months 5-8 in a 12 month system. If I had to err outside that, I might do it a little earlier, just out of excitement and to see if it's everything I'd thought. But I wouldn't do it first.

Personally I would like to get surgery & general surgery done with just to have it out the the way. As they would be my 1st rotations I'm expected to be an imbecile, so they would have to cut me some slack, right?

Very little. Most folks try to start out with a rotation they don't care so much about. For me, it was OB-GYN, which was perfect. I was pretty certain I wasn't going that direction, and it has an ideal mix of primary care and surgery. So I learned the systems and terminology for both the OR and office setting right away.

Also, I figure if I can get psych to be my last 3rd year rotation I won't be a complete idiot by then and might even know something. What do you think about that? IM, the other important rotation for psych I'm told, would be halfway in the year

It's up to you, but I really wouldn't do my favorite rotation last. The amount you'll be burnt out by the end of third year should not be underestimated.

 

[st2205]

I think there was a thread on the rotations forum about sequencing of 3rd year and what is most helpful. Most people said to start with medicine. My neighbor is a third year and started with psych but said that the shelf actually contained a lot of medicine on it. I'm surprised that they are having you plan fourth year. I hope I don't have to begin planning that until at least toward the end of third. Anyhow, I'm hoping to knock out a few rotations before starting psych so that 1) I'll be a bit more comfortable with what I'm doing and 2) so that I'll have something to compare psych against to decide my interest independent of the chaos of getting used to third year.

As far as definitions, an elective is taking anything you want, a selective is choosing from a list (i.e. a medicine selective where you can take cardiology, nephrology, GI, ID, etc.) and a sub-I (substitute internship) or AI (acting internship) is a fourth year rotation where you're somewhat treated like an intern in terms of responsibility. Obviously I've never done one so maybe someone else can give a better explanation.

As far as what other electives to do, I've wondered this same thing and the general concensus around here is to for sure do endocrinology.. that's about the only one that seems to get brought up frequently. Also to get broad experiences and not duplicate what you'll see in residency, which I agree with. I'm planning on likely doing a lot of the IM subspecialties (cardiology, nephrology, GI). I think one that looks pretty interesting, and pretty relevant, but isn't really ever mentioned is medical toxicology. What were you thinking of taking?

 

[notdeadyet]

What's an elective vs. a sub-I (or is it sub-1??) vs a selective?

The idea is that a sub-internship (aka AI or acting internship) is a fourth year elective in which you're expected to take on more patients, hours, and responsibilities and function essentially at an intern level. Some departments and programs don't make much of a distinction between electives and sub-I's, but others do.

I've never heard of a selective. Hopefully someone else can help you there.

In our 4th year we are required to do an "amb surgical sub-1 selective" as well as "medical sub-1" but I have no idea what these mean.

Could it be a "sub-I"? I'd definitely clarify with your school, but it sounds like they're expecting you to do a medical sub-internship. Not sure what a "ambulatory surgery" sub-internship is. Our school requires an "ambulatory" sub-I, but that refers to not-inpatient.

I am already lining up a 4th year elective psychiatry rotation (or sub-1 or whatever). I have ties to the military and am looking at an inpatient unit that deals with mostly PTSD and suicides. Is that ok? What should I be looking for when picking these 4th year rotations?

You'll spend 4 years doing a psychiatry residency, so I'd try to spend fourth year doing as many rotations as possible in things you're likely to not specifically cover in residency. I wouldn't sweat PTSD specifically, as you'll have plenty of exposure to it in your military residency. Any inpatient unit is likely to have lots of suicidal behavior exposure. The military tends to discharge folks with hard-core psychiatric conditions, so you might consider a rotation that has lots of inpatient treatment for this. Then a broad selection of electives would probably serve you well. You'll be studying plenty of psych for four years, but limited rotations in medicine. Take advantage of fourth year to beef up your skills.

Best of luck with third year. A common expression in the Army is that the most important thing is showing up in the right place at the right time in the right uniform. Apply that to third year and you're halfway there. Exciting times ahead for you.

 

[pingouin]

Neither. Talk to your school upperclassmen that you know. Everyone has their own ideas about the sequence of third year clerkships, but at the end of the day, it doesn't make as much difference as you might think.

Agreed. I'm midway through M3 year and am glad I picked the schedule I have, but can see advantages to having done things differently.

That said, I wouldn't do my most likely residency's clerkship first or last. You will not be at your best at your first rotation, as you'll be still learning the EMR, how to do H&Ps, how to write notes, and how to interact with patients and staff. Folks tend to do worse on their shelves and honors are harder to come by. You also probably don't want it as one of your final rotations. If you work hard on every rotation (and not everyone does), by the time you get to your last rotation, you can be pretty burnt.

The sweet spot in most people's minds tends to be around months 5-8 in a 12 month system. If I had to err outside that, I might do it a little earlier, just out of excitement and to see if it's everything I'd thought. But I wouldn't do it first.

This is similar to the advice given by classes ahead of us. Same rationale- enough time to know the system a little bit better and have some experience under your belt before you get to your "top choice" rotation, early enough that you're not burned out.

Very little. Most folks try to start out with a rotation they don't care so much about. For me, it was OB-GYN, which was perfect. I was pretty certain I wasn't going that direction, and it has an ideal mix of primary care and surgery. So I learned the systems and terminology for both the OR and office setting right away.

Agreed- very little slack given. I did the same as NDY- started with something I knew I wouldn't want to do. In my case, it was surgery. My entire cohort HOPED for slack, although didn't expect it, which is good because it wasn't there. Then I moved on to internal medicine, which I wanted to get in before I did psychiatry. Now I'm on psych/neuro- just finished neuro on Friday and will start psych tomorrow.

Knowing the OR setting (ie, sterile field) has been helpful when there have been IM and neuro procedures, as I was able to set things up for LPs, thoracenteses, etc, for my residents. I think the IM months will help me especially when I'm on consults, but I'll have to wait a few weeks to see when I start that part of my clerkship.


We've also had several people in our class who have been relatively sure about a particular specialty find out that they absolutely love something they had never thought of, or expected to not like. I expect there will be a lot more of that by the end of the school year.

 

[whopper]

I agree with all the above though I emphasize a lot of this may be school and site dependent. Depending on how a school and program organize themselves, things can highly vary.

As mentioned above, ask people in your program who've been through this.

 

[235750]

Thanks everyone for the great advice. I will look at scheduling my psych rotation sometime before I get completely burnt out!

Thank you notyetdead for explaining the terminology. I should add those to Urban Dictionary...

I'm not doing a military residency BTW, I was a civilian contractor for years and helped create their EMR system so I have some mil med contacts is all. I thought it would be interesting to do an elective at a military institution, and this particular hospital is fairly decent and already has an MOA with my school. (I don't know what MOA means except that I don't need any paperwork.) Also, I've published and will publish again with some of the staff, so knowing that the people there are nice is good too

Notyetdead, I hear you re: taking rotations that are not psych related. But as I want to be a psychiatrist, what would impress PDs the most?? Do they care what I take for my sub-i or electives? Are there any essential electives/sub-Is that I should take? Child, addiction, etc ( I have no interest in fellowships at the moment)?

I have no idea what other electives I'll take. To be honest I am still in a state of shocked that my preclinical days are dwindling.... I'm fairly certain that I still don't know anything

Thank you again for everyone's help!

 

[whopper]

Are there any essential electives/sub-Is that I should take? Child, addiction, etc ( I have no interest in fellowships at the moment)?

I would do the non-psychiatric fields that touch upon psychiatry the most: neurology, Ob-Gyn, endocrinology, GI, and primary care.

Some of the fields that don't interact with as quite as much are surgery, sports medicine, anesthesiology, opthalmology among a few others that I'm sure are not coming to mind.

Be mindful that in any field of medicine, there will always be specialized pockets where they may become heavily behavioral science related. E.g. in the area of plastic surgery, there are several who believe that the person's decision to have a it done may be a result of a psychiatric disorder. For that reason, there are several who believe that a psychiatric or psychological consultation should be done on anyone who wants some changes done to their face. Hey, I just told you that surgery usually doesn't interact much with psychiatry. See what I mean?

If you could for example find a radiology rotation where they are actively checking out several MRIs of the brain (or even better--PET scans) you should consider it. The reality, however, is that a radiology rotation will usually be you checking out CT scans and X-rays. That IMHO will not have much relevance in psychiatry compared to the former.

I can tell you that often psychiatric patients complain of GI related symptoms (e.g. anxiety causes them to have abdominal cramps), they have symptoms that could be interpreted as having neurological problems, hormones are heavily related to mood states, and many psychiatric patients have disorders that should be handled by a PCP that are ignored.

 

[235750]

I would do the non-psychiatric fields that touch upon psychiatry the most: neurology, Ob-Gyn, endocrinology, GI, and primary care.

Thanks whopper, primary care is another interest of mine so that works out great

If anyone else can think of a wonderful rotation they'd suggest, please post!

 

[st2205]

If anyone else can think of a wonderful rotation they'd suggest, please post!

Below is a list, more or less, of rotations you could do. In my own unqualified, arbitrary opinion I was going to break a lot of these into categories according to relevance and importance to general medical education (in context of being a 3rd/4th year elective). I'm a little tired and will post later, but I wanted to paste this list so I can have it as a reference when I'm feeling more motivated.

Specialties

Aerospace Medicine
Allergy and Immunology
Anesthesiology
Colon and Rectal Surgery
Dermatology
Emergency Medicine
Family Medicine
General Preventive Medicine
Internal Medicine
Medical Genetics
Neurological Surgery
Neurology
Nuclear Medicine
Obstetrics and Gynecology
Occupational Medicine
Ophthalmology
Orthopaedic Surgery
Otolaryngology
Pathology-Anatomic and Clinical
Pediatrics
Physical Medicine and Rehabilitation
Plastic Surgery
Preventive MedicinePublic Health
Radiation Oncology
Diagnostic Radiology
Surgery-General
Thoracic Surgery
Urology

Subspecialties

Abdominal Radiology
Adolescent Medicine
Adult Cardiothoracic Anesthesiology
Adult Reconstructive Orthopaedics
Blood Banking/Transfusion Medicine
Cardiovascular Disease
Chemical Pathology
Child Neurology
Clinical Cardiac Electrophysiology
Clinical Neurophysiology
Congenital Cardiac Surgery
Craniofacial Surgery
Critical Care Medicine
Critical Care Medicine
Cytopathology
Dermatopathology
Developmental-Behavioral Pediatrics
Endocrinology, Diabetes, and Metabolism
Endovascular Surgical Neuroradiology
Foot and Ankle Orthopaedics
Forensic Pathology
Gastroenterology
Geriatric Medicine
Hand Surgery
Hematology
Hematology and Oncology
Hospice and Palliative Medicine
Infectious Disease
Interventional Cardiology
Medical Biochemical Genetics
Medical Microbiology
Medical Toxicology
Molecular Genetic Pathology
Musculoskeletal Oncology
Musculoskeletal Radiology
Neonatal-Perinatal Medicine
Nephrology
Neurodevelopmental Disabilities
Neuromuscular Medicine
Neuropathology
Neuroradiology
Neurotology
Nuclear Radiology
Oncology
Ophthalmic Plastic and Reconstructive Surgery
Orthopaedic Sports Medicine
Orthopaedic Surgery of the Spine
Orthopaedic Trauma
Pain Medicine
Pediatric Anesthesiology
Pediatric Cardiology
Pediatric Critical Care Medicine
Pediatric Emergency Medicine
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Hematology/Oncology
Pediatric Infectious Diseases
Pediatric Nephrology
Pediatric Orthopaedics
Pediatric Otolaryngology
Pediatric Pathology
Pediatric Pulmonology
Pediatric Radiology
Pediatric Rehabilitation Medicine
Pediatric Rheumatology
Pediatric Sports Medicine
Pediatric Surgery
Pediatric Transplant Hepatology
Pediatric Urology
Procedural Dermatology
Pulmonary Disease
Pulmonary Disease and Critical Care Medicine
Rheumatology
Selective Pathology
Sleep Medicine
Spinal Cord Injury Medicine
Sports Medicine
Surgical Critical Care
Transplant Hepatology
Undersea and Hyperbaric Medicine
Vascular and Interventional Radiology
Vascular Neurology
Vascular Surgery

 

[st2205]

I've seen this question about what rotations to take come up numerous times over the past four years or so and there's periodic response, but never a whole lot besides most people saying endocrinology is a good one. Anyway, one caveat is that I'm probably the least qualified person on this board to weigh in with any opinion, but after realizing medical school is short and there are a lot of things available, the following is more a reflection of the way I have thus far viewed things in approaching clinical electives. I'm open to any and all forms of correction, advice and/or encouragement.

The criteria I have developed was done on the fly and is nothing more than my opinion. A lot of the statements regarding a rotation in any particular specialty reflects general assumptions and biases I may possess with little experience with many of the said fields, so whether or not any particular rotation would help anyone understand, or gain from the experience, what I'm thinking it will, I couldn't say for certain. The categories don't necessarily relate any kind of importance (i.e. specialty x is listed in Class III but is more important than specialty y in Class I). I tried to separate that which is absolutely essential for a physician and directly relates to psychiatry (Class I), that which is foundational to medicine and certainly does would relate to psychiatric practice but in a more general manner (Class II), rotations that may potentially provide some type of benefit into understanding some of the nuances of psychiatric practice (Class III), and those of undetermined significance (Class IV). The last one is more a list that didn't quite fit into the first three criteria for any particular reason (ultra-specialized, small field, or may be largely dependent on the individual, where they do their rotation, and what their goals are).

Class I (essential / primary relevance)

Emergency Medicine: A lot of overlap in populations, just in more acute settings. I would imagine it would be pretty essential in practicing emergency psychiatry. I'm quite certain just about every school requires this at some point in years 3 and 4.
Family Medicine: They write the most prescriptions for psychotropic medications. Your patients, as mentioned here and in other threads, will not get good care from a GP (generally speaking) and being familiar with FP enough that you will recognize what you can treat and what you need to refer would be essential.
Internal Medicine: Needs no explanation.
Neurology: Again, I think most schools will require this, but it seems (to me) that only two months of neurology during residency may not be doing it justice.
Obstetrics and Gynecology: Half your patients will be female and, at one point or another, may be pregnant. May also see more with regard to postpartum depression.
Endocrinology: As has been mentioned, many endocrine problems with psychiatric manifestations. Also, diabetes patients will also be seen in every specialty.
Medical Toxicology: ODs, suicide attempts, MAOI and/or other psych med interactions (not sure how much you'd see of the last one).

Class II (foundational)

Allergy and Immunology: I remember a girl telling a story about going into anaphylactic shock on an inpatient unit but the staff dismissed it as being due to her condition. I would also imagine that, with allergy and immunology being hot topics in the field of psychoneuroimmunology that being familiar with presentation and treatment of allergy could be beneficial.
Dermatology: Psychiatric patients seem to have a lot more problems with skin (also see IV drug users).
Adolescent Medicine: My understanding is that you see a lot of psych. Given the nature of the age group, you'll deal with a lot of other psychosocial issues (sex, drugs, etc.)
Cardiology: Will see a lot of cardiac patients regardless of specialty. Probably want to understand implications of psychiatric meds on them and drug interactions.
Critical Care Medicine: Building a better foundation in IM.
Gastroenterology: See Whopper's explanation.
Infectious Disease: Psych patients would likely be at higher risk for many IDs.
Nephrology: Will have many patients with hypertension regardless of field, may also have patients with kidney problems. In any case, solidifying foundation in IM.

Class III (situational)

Anesthesiology: ECT patients are under general anesthesia?
Colon and Rectal Surgery: Foreign insertions pertinent to psychiatric practice?
Neurological Surgery: I'd imagine the argument could be made of behavioral manifestations pre- and post-op.
Developmental-Behavioral Pediatrics: Different patient population than child psych but may be good to expand on that, especially from different perspectives.
Forensic Pathology: Suicides? Abuse? Overdoses?
Geriatric Medicine: A lot of psychosocial things going on.
Hospice and Palliative Medicine
Neuroradiology: Imaging may have a bigger role in the future?
Oncology: Important with C/L.
Pain Medicine
Pulmonary Disease
Rheumatology
Sleep Medicine
Pediatrics
Surgery-General

Class IV (of unknown importance)

General Preventive Medicine
Occupational Medicine
Otolaryngology
Plastic Surgery
Child Neurology
Clinical Neurophysiology
Neurodevelopmental Disabilities
Neuropathology
Vascular Neurology

In the end, I believe the idea is to get a really good foundation in medicine, which is why I (in my noviceness) I think it's important to hit a lot of the high yield more general fields (cardiology, GI) rather than super-specialized areas or lots of electives in your specialty of choice.

 

[Manicsleep]

A selective is usually an elective out of a group of electives that must be taken. I have only seen it in transitional programs.

Lets say you are going into surgery, you have 2 surgery selectives and your choices would be all the surgical subspecialties. However, someone going into radiology may have a different set of choices. Its an elective but with a limited set of options...you must select from options that have been selected for you.