advice (for a last minute concern)

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
rkaz

rkaz

Full Member
15+ Year Member
Joined
Mar 18, 2008
Messages
1,008
Reaction score
139
Hi guys. So you know I am applying for residency in psych this year, and am super happy about the process and all the great interviews I've gotten thus far.

There is just this tiny thing that is bothering me, which I wanted to ask you about... I know I should have asked it earlier, but consider this as just tepid feet before the wedding (where you know you are making the right decision, but you get a little scared before saying the "I do"s).

Here's the situation: I absolutely LOVE outpatient psych with a passion. Outpatient psych has been my favorite time in all of med school. And I REALLY like my child psych rotations. I get super happy to go to my rotations each day as I truly enjoy being there. 😍 I enjoy kids, and love the adolescents and young people (like up to college student age).

The issue is that I don't enjoy inpatient adult psych very much. With inpatient, the people are often too sick, and I don't get that sense of reward that I'm making much difference. I also don't like walking through the wards being hypervigilant that someone might beat me up (as I'm petite and the patients often tower over me). When I work with younger people who are still developing, I feel like I can have a more positive impact on their lives to really make a difference and (hopefully) help them find a better path.

It just scares me a bit that I don't like the inpatient psych units that much. I can do it... it's tolerable. But I don't love it. I'd almost rather do inpatient IM than inpatient psych... that's what scares me. But when it comes to outpatient psych (especially working with young people), I am feel like I wouldn't want to be doing ANYTHING else, as it is a perfect fit for me. It truly makes me happy.

Thoughts? Is not liking inpatient psych so much a bad thing?? I do understand I will have to get through it in residency, and I'm fine with that. Just was hoping that it wasn't something to be too worried over with choosing psych as a specialty. I know I'm going into psych anyway, so I don't know if it makes any sense to even ask the question. But I was hoping someone could either comfort my doubt or give me some perspective. Thanks!
Members don't see this ad.
 
rkaz said:
Hi guys. So you know I am applying for residency in psych this year, and am super happy about the process and all the great interviews I've gotten thus far.

There is just this tiny thing that is bothering me, which I wanted to ask you about... I know I should have asked it earlier, but consider this as just tepid feet before the wedding (where you know you are making the right decision, but you get a little scared before saying the "I do"s).

Here's the situation: I absolutely LOVE outpatient psych with a passion. Outpatient psych has been my favorite time in all of med school. And I REALLY like my child psych rotations. I get super happy to go to my rotations each day as I truly enjoy being there. 😍 I enjoy kids, and love the adolescents and young people (like up to college student age).

The issue is that I don't enjoy inpatient adult psych very much. With inpatient, the people are often too sick, and I don't get that sense of reward that I'm making much difference. I also don't like walking through the wards being hypervigilant that someone might beat me up (as I'm petite and the patients often tower over me). When I work with younger people who are still developing, I feel like I can have a more positive impact on their lives to really make a difference and (hopefully) help them find a better path.

It just scares me a bit that I don't like the inpatient psych units that much. I can do it... it's tolerable. But I don't love it. I'd almost rather do inpatient IM than inpatient psych... that's what scares me. But when it comes to outpatient psych (especially working with young people), I am feel like I wouldn't want to be doing ANYTHING else, as it is a perfect fit for me. It truly makes me happy.

Thoughts? Is not liking inpatient psych so much a bad thing?? I do understand I will have to get through it in residency, and I'm fine with that. Just was hoping that it wasn't something to be too worried over with choosing psych as a specialty. I know I'm going into psych anyway, so I don't know if it makes any sense to even ask the question. But I was hoping someone could either comfort my doubt or give me some perspective. Thanks!
Click to expand...

Have no fear. Inpatient is a very small part of the specialty.I do believe most inpt units are manned by residents these days. Expect to do it for the first 2 years of residency.

Inpatient Psych < Inpatient Medicine? To each his own! lol...
 
A lot of residents approach inpatient as something that must just be endured to get to their real goal. So you won't be alone in that, by any means. Personally, I was that way too, but I ended up swinging back the other way after feeling isolated and bored with outpatient for a few years. Now I like my teams, I like the intensity, I like the problem-solving aspects of it, and I love it as a venue to teach. So be prepared to be surprised...
 
Members don't see this ad :)
If one can pivot their expectations in residency from enjoyment to education and utility, then Inpatient psych is incredibly relevant.

I remember being chief resident and I was aware people weren't happy with working on the inpatient unit all the time. My goal as their supervisor was to make it tolerable, but primarily to make it useful to them to help them become good psychiatrists. Remember that's the goal.

Inpatient and working with intensive and severe cases is an important skillset because it helps you deal with emergencies and exacerbations. Once you know how to deal with people in a structured environment, then you move to an environment where you have a lot less control and surveillance (outpatient). Inpatient is a good environment to learn in because there's a lot of containment if you screw up as an intern.

Furthermore you will learn what happens and doesn't in a hospital, which helps you to make a much more informed decision about whether to hospitalize someone (knowing what can and can't be done in a hospital, and what will probably happen).

You will make a difference there, though you may meet disillusioned ppl sick of the revolving door. This isn't because your strategies are ineffective, but just incomplete a lot of the time (not changing the family environment, for example). That's still something to learn from.

Finally, I think inpatient is a great place to try out some brief therapies, where you can observe the outcome a lot more closely than in outpatient.
 
Wow, thank you all so much for the replies. Definitely some food for thought here. 👍

OPD, thanks for your perspective. I agree that I should keep an open mind, as things may change in the future. I often find that I like what I am good at, and it may be my increased discomfort (at inpatient vs outpatient) that contributes to my not liking it so much. However, once I become more comfortable with managing inpatients, my feelings towards being on the wards may change.

Nitemagi, very thoughtful post... thank you. I really like your comment on enjoyment vs education/utility. Right now, I'm thinking purely from an enjoyment perspective. If I start re-framing my thinking while on my inpatient psych rotations, and realize that my experiences are making me a better doctor - I think that would really help. Your post gives me something to reflect on. Thanks!
 
Only a small fraction of us like inpatient, emergency, child, dual, dbt, etc. Those are all things I like and get to do. Most of my friends would involuntarily commit themselves if they had to do those things. It's a big tent.
 
PhinyGage said:
Inpatient Psych < Inpatient Medicine? To each his own! lol...
Click to expand...

Hah, well I have to admit that my perspective of inpatient IM came last year as a 3rd year medical student. I only had to present 2-3 patients to the attending each day, which gave me plenty of time to spend online on Up-to-date. I really enjoyed putting together the theoretical knowledge with the patient's clinical presentation, as the problem-solving aspect was fun for me.

I realize however that inpatient IM as a resident/intern may be quite different as the level of responsibility is much higher, and I'd have a lot more patients. Thus I probably wouldn't have the time to deliberate about what to do for the patient while reading up about things online, as I'd have to move a lot faster, which may not be as fun. I admit I'm actually a bit nervous about juggling 9-10 patients on my IM rotations next year... as I don't want anyone to fall through the cracks under my care. :scared:
 
well that's the thing, inpatient psych as a resident is a very different experience than as a med student (at least it should be). I absolutely hated inpatient psychiatry with a passion as a medical student, and liked psychiatry because of consultation-liaison psychiatry. i was absolutely dreading inpatient psych (and we have 10 months of general adult inpatient at my program, more than most) but i enjoy it for the following reasons:

1. i get to do tons of teaching with med students
2. i get to manage medical comorbidities
3. i get to work with acutely disturbed individuals and see extreme pathology
4. i get to do intensive psychotherapy (CBT, dynamic, existential) with really sick (and not so sick individuals)
5. i get to run groups
6. i get to work closely with others (e.g. nurses, social workers etc)

most of these (except for the groups) you dont really get to do in oupatient months during residency. you also get fairly confident in managing suicidal/homicidal individuals which i think outpatient docs tend to get flustered with.

i have no intention of practicing inpatient psychiatry however.
 
I also tend to like everything outpatient, though inpatient psych is still > in patient med. I find that in most inpatient settings, it's a lot less about direct patient contact (which is really why I did medicine in the first place) and a lot more about being part of a team, doing the necessary paper work and managing acute complications. At least in inpatient medicine, you get to spend like 5 minutes with the patient during the day and that is basically just to check how they are doing and do a quick physical exam. Definitely not my ideal view of what medicine is.
 
I think you have to be able to manage the sickest, most acute patients before you can competently manage a less acute outpatient practice. It gives you perspective on how bad things can get, indications to hospitalize, familiarity with decompensated psychopathology, management of acute crisis, and a number of other things. I too was less sold on this idea until I interviewed at Hopkins and the way one faculty member explained it really clicked. That said I always liked the inpatient unit, although I like the outpatient world more.

I think if outpatient is what you love then you should go for it. In psychiatry residency you will have under two years of required inpatient psych exposure (likely ~4 mo first year and 6 or more second year) in addition to emergency psychiatry with admissions to the inpatient unit. You will also do likely 2-4 mo total consult-liason which has a very different feel to it. You can learn a lot and then move on to third year where inpatient is mostly a thing of the past. Once you are out in practice you can choose (as many do) to never work on an inpatient unit again.
 
I hate to say this but inpatient psych and psych triage ARE a big part of residency. You should manage your expectations, inpt is just where pts go to get stable, the real work is in the outpt. Don't expect to completely manage all of the pts' symptoms in the 5-7 days you are given, if they are safe enough to be let out that is all you need to worry about.

When you say adult psych, do you mean the geriatric population or anyone over 18? Geriatric psych is soul crushing but you will just have to deal with it. The demand for psychiatrists in this population will only grew and it would do you well to learn about them thoroughly.
By younger pts, do you mean kids? Again, I hate to burst your bubble but in my experience most parents want to blame you for "curing" their kids rather than explore their own deficits as parents. You may find kids even more frustrating because the identified patient is often not the one in the family that needs a psychiatrist.
 
I'd echo other posters who urged you to focus on the utility and learning that happens in these rotations. These rotations are a great place to learn about medications, especially antipsychotics and mood stabilizers, and to learn to recognize when a psychiatric patient is "sick."

If you do 100% outpatient work, you want to understand how inpatient units operate because sometimes your patients will need to go there. You'll be better able to explain to your patient what to expect and why you are sending him/her there, which is invaluable for the treatment relationship. You'll have more confidence about when to hospitalize patients involuntarily or suggest a voluntary hospitalization because you'll understand when and how inpatient units can be useful. You'll be able to recommend more intensive treatments like ECT and Clozaril because you'll have seen patients improve on these while hospitalized.

Also, once you have learned more psychotherapy, you'll find that there is a way to integrate this into your inpatient work to make it more rewarding. This may not be possible in the early years of your residency, but if you moonlight on inpatient units later in residency as many of us do, you can try it out then and see if it changes the character of the work for you.
 
Being exposed to all aspects of the field (or as many as your residency allows you), is what makes you a well rounded physician. So you'll understand what is going on with inpatient, emergency, consults, outpatient, psychotherapy, geriatric, addictions, child, etc. Learning all of this, even if you don't want to ultimately work in that setting is what makes a psychiatrist. NP's don't do this. Psychologists do not.
 
splik said:
well that's the thing, inpatient psych as a resident is a very different experience than as a med student (at least it should be). I absolutely hated inpatient psychiatry with a passion as a medical student, and liked psychiatry because of consultation-liaison psychiatry. i was absolutely dreading inpatient psych (and we have 10 months of general adult inpatient at my program, more than most) but i enjoy it for the following reasons:

1. i get to do tons of teaching with med students
2. i get to manage medical comorbidities
3. i get to work with acutely disturbed individuals and see extreme pathology
4. i get to do intensive psychotherapy (CBT, dynamic, existential) with really sick (and not so sick individuals)
5. i get to run groups
6. i get to work closely with others (e.g. nurses, social workers etc)

most of these (except for the groups) you dont really get to do in oupatient months during residency. you also get fairly confident in managing suicidal/homicidal individuals which i think outpatient docs tend to get flustered with.

i have no intention of practicing inpatient psychiatry however.
Click to expand...

This. I thought I'd hate inpt psych for the same reasons you do, but now that I'm outpatient, these are all the things I miss...
 
Thanks so much everyone for your comments. 👍 I'll try to approach my inpatient months from a different perspective and keep an open mind. I hope that I will eventually come to appreciate it, as many of you have.
 
Not all inpatient units for psychotic patients. Look around and you'll see there are plenty of programs that have the majority of their inpatient work with depression, anxiety, and/or personality disorders.

That said, I agree with the above that psychotic disorders and mania are core parts of psychiatry.
 
Last edited:
Not to derail the thread, but does anyone else feel the opposite? I'm a PGY1 dreading the outpatient-only PGY3 year. I absolutely love inpatient psych (and inpatient medicine) but being stuck in clinic all day, whether for psych or medicine, drives me crazy. I'm trying to develop a positive attitude towards outpatient training because I know that it is such an important experience and because I know that there is no way to actually know what it will be like to follow and treat patients...maybe I'll love it...
 
m1345 said:
Not to derail the thread, but does anyone else feel the opposite? I'm a PGY1 dreading the outpatient-only PGY3 year. I absolutely love inpatient psych (and inpatient medicine) but being stuck in clinic all day, whether for psych or medicine, drives me crazy.
Click to expand...
I was kind of in your shoes.

Most folks on SDN, and folks going into psychiatry in general, are interested in outpatient psychiatry, particularly the private pay model. I have always been interested more in inpatient and acute psychiatry. I was apprehensive about the outpatient months.

I'm now at the point in my training where I've done as much or more outpatient psychiatry as inpatient psychiatry. I still prefer inpatient and keep psychiatry and that is my goal professionally, but I very much enjoyed the outpatient training. Regardless of your career goals, both your inpatient months and your outpatient months will only be wasted time if you have a closed mind or very poor training.

If you are interested in going the outpatient route, you will learn great things on inpatient psychiatry about risk assessment, level of care referral, and flare up management. This will be directly applicable to your outpatient work.

If you're interested in going the inpatient route, you will learn great things on outpatient psychiatry about building alliance, motivational/supportive psychotherapy, CBT, and good psychodynamic formulation. This will be directly applicable to your inpatient work.

Keep an open mind, keep your ears and eyes open, and most of your rotations in residency will be applicable to whatever work you end up doing.
 
m1345 said:
Not to derail the thread, but does anyone else feel the opposite? I'm a PGY1 dreading the outpatient-only PGY3 year. I absolutely love inpatient psych (and inpatient medicine) but being stuck in clinic all day, whether for psych or medicine, drives me crazy. I'm trying to develop a positive attitude towards outpatient training because I know that it is such an important experience and because I know that there is no way to actually know what it will be like to follow and treat patients...maybe I'll love it...
Click to expand...

I prefer inpatient over outpatient, but outpatient is not so bad that you have to dread it.
You will learn a lot from it, and occasionally it can be interesting to see how a certain patient changes over the year.
 
You must log in or register to reply here.
Top