Just little things, like not being sure whether a particular patient truly fits the diagnostic criteria for a particular disorder, not really being sure how to teach my med students or answer certain questions they ask me, sometimes not fully being able to answer patients’ questions about medications. Moreso the teaching/being a mentor to med students thing I guess, which I’m a bit self-conscious about since I remember some of my classmates early in MS3 year talking about who were the bad interns vs the good interns.
I’d definitely like to read up more on interviewing and developing clinical acumen during the diagnostic interview. What do you think of the DSM-5 pocket guide (little purple book), or are there better resources?
Yeah, I think it might have been nice to start with most of the off-service stuff so I could truly learn and be comfortable with becoming an intern before I learn how to be a psychiatrist. Alas, my schedule’s a bit of a mish-mash as it likely is in most programs, and most of my off-service stuff is in the second half of the year.
Well it's good that your nonpsych rotations are later. You can focus on psych. If you aren't sure on diagnosis, the pocket DSM 5 in your pocket- perfect for on the spot. I started at a brand new program and we didn't have to teach med students. It was actually outpatient first. At my second program (I switched my PGY 3 ) interns didn't teach students, so that would be tough. Be nice to the students. I hated the "mean" residents. I tried to help med students with questions I recalled from the shelf exam, that's what they were most concerned about. I carried Stahls prescriber guide with me and still have it with me when I work and if I am prescribing a med I don't usually prescribe or I'm not sure if a certain dose I want to prescribe comes in that dose or if I need to write it as a higher dose and take half . Pull your Stahls or whatever book you are using for psychopharm that fits in your pocket out with patients and med students is my advice, you can read aloud to your patient and let the patient see the information as well, a lot of patients are concerned about sedation or weight gain and Stahls has a great diagram for both of those plus side effects , starting doses. They will get the needed information and you will learn.
You are just starting. You are an intern. If you knew all there was to know, you wouldn't need to be an intern. This is the time to learn and grow. Unless your attendings are criticizing you, I wouldn't stress. And don't compare yourself to the other residents. I was the superstar at my first program and fast forward, I am trying to pass the psych certification board for the THIRD time and I am dying to switch to another field. I had done a ton of psych electives so it was so easy for me intern year.
If your program allows, ask an attending or senior resident to watch you do an initial eval and provide constructive feedback, and watch your attendings and senior residents and see how they do it, watch the patient as your attending or senior resident is interviewing a patient, how does the patient respond? But in the end you will and should develop your own style. You need to get x info while building a rapport with the patient. Your style may be different from others. My style was different from what others did, but it was mine. I personally let the patient talk for 20 minutes if the patient was open, some patients have been dying for someone to truly listen to them, and they told me a ton of the information I needed and whatever information they didn't give me I would ask in the next 25 minutes if it took that much time. If they told me something painful I would say "that must have been difficult" if they overcame an addiction or adversity, I would say that was a great accomplishment.
The hardest part for me was when the patient would ramble on and on and I didn't want to be rude but in reality they probably could have gone on and on for hours and I didn't have time for that so I had to learn to say, that's important and when we meet later, we can discuss that more. With patients who aren't so forthcoming, I tried to help them relax. I would tell them that it was ok to be nervous, ask them to take a few deep breaths and breathe with them. I would tell them most patients were nervous in this situation to normalize it for them but explain that I was asking questions in order to best help them. For the patients who were not willing to be interviewed, I would say I understand you have been asked these questions or I understand you are tired (if they are playing asleep or even sleeping), but I really want to help you, I will make this as brief as possible if you would like and then you can go back to bed. It's all about making the patient the most comfortable. And let there be pauses. Sometimes you get the most important information if you just wait a few minutes and the patient just blurts out key info that they wouldn't have if you just kept going down your checklist. I think there are books and probably you-tube videos on how to interview or maybe get together with your fellow interns and practice being the psychiatrist and patient if you think that would help.
I had a patient suicide early in my second year of residency, so did two other residents. The other residents appeared fine. I had a really difficult time and it was apparent to my attendings. My PD at the time said I HAD to see a therapist when I wasn't "getting over it" soon enough (I had realized prior to this I wanted to do FP )and I learned so much about therapy by being a therapy patient. I saw one therapist who was AWFUL and learned what not to do and the second therapist was a psychiatrist who did psychoanalysis and it was a great fit. A lot of residents in my program ended up going to therapy. My psychiatrist said it was the norm when he trained for pretty much all of the residents in his program to be in therapy and he was. Psychiatry seems to be trending more toward med management and less to therapy but you do have to do x amount of cases in each therapy modality, so maybe consider therapy to deal with being a resident or any other issues you may have.
It's awesome that you are trying to learn, but be gentle with yourself. You are just starting out. If one could just jump to attending status without a residency I could just be a FP or Cardiologist tomorrow, but the point of residency is to learn , you aren't expected to know everything August of PGY-1. The DSM IV was a lot easier than DSM 5 IMO with all of the different modifiers to each disorder. What you are doing now sounds great. If your program has a strong didactic program, read ahead on the topic and ask questions. Like you mentioned, pick a patient you saw that day and review the diagnosis, the differentials. the med you picked and maybe some about that whole class of meds. I personally love Beat The Boards. And one thing I didn't do during residency which I wish I would have is to also make time for you, hang out with your friends who aren't in the medical field, don't stop doing all of your hobbies. What I did to help anxiety was swim. We tell patients to exercise, I followed that advice. I like swimming, so I joined a gym and swam and it gave some of the stress a place to go. Try to live a semi-balanced life, not easy as a resident, but important. What I DID do that I thought helped was about 2 weeks into a rotation was to pull my attending aside and ask for constructive criticism. That was so helpful and it shows your attending you want to improve.
I hope this was somewhat helpful. I hope someone else chimes in and adds some advice.
