MacDonaldTriad

5+ Year Member
Mar 13, 2013
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still on the right side of the dirt
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Don’t despair, when eyeing perspective MS-IV applicants, how much they know is of less concern than you think. It is much more about how well you learn and how mature and seriously they take learning. It is always nice to have new interns who seem to know a lot, but we get a lot of smart people who know a lot that came become so so psychiatrists at best.

My advice is that you approach an attending or senior resident and tell them that you perceive your short comings and would welcome any suggestions and extra help in learning the pertinent positives and negatives in psychiatry. Ask the attending or senior resident to let you present a case you are working with and have a discussion about the differential and what key parts of the history make a difference in determining the attending’s/resident’s lead diagnosis. Then re-present with a focus on those key parts. At best, you will flatter the attending/resident by adopting his or her wisdom and way of thinking (even if it is wrong), and at worst, you will find out that at least this one attending/resident isn’t willing to teach and you wouldn’t want to train there anyway. It really is a win win for you. Don’t forget that “auditions” are two way streets.

A couple of points of caution: Even the best programs may have an attending or resident that is not motivated to teach. A sample of one is a small piece of the elephant. The other caution is that common wisdom would place the attending as more important than a resident. This might be generally true, but it depends upon who sits on the admissions committee. Attendings who are marginal teachers tend not to be involved in the selection process, and a chief resident can speak for the resident’s general impression.

Program director: “How was your Sub-I last month”

Attending: “He/she was fine, I’ve seen better, but they seemed to be able to do the work.”

Resident: “I was on service with this medical student and everyone seemed to like him/her and he/she seemed to really care and try.”

Program director’s internal dialog: “Hmm... The student is fine, able to do the work and is really trying. This one just made the cut.”
 
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Bartelby

10+ Year Member
Mar 15, 2007
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Attending Physician
I agree with MacDonaldTriad, asking for feedback from a resident or an attending is pretty important at this point. When I work with a visiting MS-IV I try to treat them like an intern as much as possible. That means they take the lead on interviewing, they tell me their diagnostic impressions and proposed treatment plan before I tell them what I think, they take the lead on presenting the patient, and ideally they do care coordination (calling other teams, calling providers) with me around to supervise. I also watch to see how/if they establish rapport with patients. The students who can do these things and then continue to seek out additional responsibility are the ones that wow me.

In your case it sounds like there is either a lack of confidence or a skill deficit. Honestly, either way that's okay as long as you show that you have identified it and take steps to improve over the course of the rotation. For presenting being able to succinctly convey all of the necessary information is key, so structure in your mind what they patient's condition is and what people will want to know. For instance, you might report on the psychomotor improvement, change in speech patterns, affect, and suicidality along with toleration of medications every day on a patient with depression, whereas a psychotic patient you might focus in more on the character of their delusions, the presence of AVH and its character, etc. Always have in the back of your mind what decisions you might want to make for that patient (medication change, outpatient referrals, disposition decisions, social interventions, consults, etc) and what information would help you make those decisions. For new patients knowing how to quickly go into relative depth on their presentation (depression characterized by [all depressive symptoms] in the setting of [largest life stressors]) with a brief mention of other psychiatric ROS and a structured way to relate their PPH, PMH, SH, FH, etc will help you. Ideally you can present a new and relatively complicated patient in full in about five minutes.

Keep at it, ask for feedback, and don't get discouraged! We all start somewhere, putting in the effort to get somewhere better is what matters.
 

hamstergang

may or may not contain hamsters
7+ Year Member
May 6, 2012
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i'm gonna probably do Psych as that's pretty similar to neurology and I can still see my kids occasionally.
Am I misreading here, or are you saying that you want to do neurology but will instead do psychiatry because it has a better lifestyle but otherwise seems like a similar field to you?
 

Dharma

7+ Year Member
Aug 12, 2010
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The Path of the Righteous, man.
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Am I misreading here, or are you saying that you want to do neurology but will instead do psychiatry because it has a better lifestyle but otherwise seems like a similar field to you?
Doesn't seem like a bad approach, assuming one enjoys psychiatry.
 
Aug 17, 2014
25
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Resident [Any Field]
Presenting in psychiatry is definitely a bit different than in other medical specialties, because you want to tell who the patient is as a person and describe their behavioral symptoms, rather than just the signs and symptoms of a physical problem. I'd recommend including the following elements:

Name, age, sex, voluntary/involuntary status, chief complaint (or reason patient was brought to the hospital), history of present illness (always screen for symptoms of MDD, bipolar, psychosis, anxiety, danger to self or others), any past suicide attempts and date of most recent suicidal ideation, past psychiatric history (briefly summarize any past psychiatric admissions and outpatient care), past medical history (mention any history of head injuries, seizures, strokes, and other pertinent problems), review of systems, allergies, current medications, past psychiatric medications, family history (focus on psychiatric disorders), developmental history (family life, education, abuse), social history (employment status, housing situation, marital status, children, legal history, substance use history). Also give the findings of your mental status examination.

After presenting the above information, offer an idea of what you think the diagnosis may be and what you would recommend for treatment. If you can present all of this in a coherent manner, you'll be golden.
 
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OP
S
Sep 21, 2014
66
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Medical Student
I just want to thank all of you for the suggestions, it truly lifted my spirits and gave me hope that I'm not a complete failure. Honestly, I think I was overthinking it and I need to practice rehearsing the patient hx in a coherent fashion a few times. I'm just hoping I get it down soon as its my 2nd week next week.

I did ask one of the attendings (only people the students have access to since this is a new program and residents are on the medicine team at another facility) to review my note and get back to me. He never followed up with me, but I'll try to talk to him on Monday. Numbers wise, I'm not competitive as I only took COMLEX. So I do have some anxiety about that and it shows when I present. I just need to pretend that its just me and the attending and the 3rd years are not there.

It's a bit frustrating having another 4th year student who is a gunner and tries to go out of their way to impress the staff and faculty. But I'm doing my best and hope that counts. This is my first in-patient psych rotation, even first time writing a psych note, my last rotation for psych was psychotherapy and I was just observing. It was a good experience lifestyle wise, but definitely not hands on. I also never learned how to talk in psych, i.e. if the patient asks you questions about your life that seem benign, how to deflect them..."so where did you go for undergrad? where do you live? how many years left of education do you have left?"

Regardless, I'm learning still and no expert, but I do have a desire to learn and follow through.

Regarding my switching from Neuro to Psych that has to do with a genuine interest in the field due to the overlap. I have a father who has been exhibiting signs of MDD throughout all our life and a mother who is BiPolar type II/type I (can't tell sometimes with her)...he truly made it a point to always give us (his children) an earful of any little thing (usually manic) my mom did. My little sister became genuinely depressed and resorted to drug use due to his constant badgering. I would say that all of us suffered from a poor self esteem throughout our childhood thanks to his psychological abuse. My familial situation is a big motivator for me to go into psych. But I also enjoy the neuro aspect of it too, (movement disorder patients who have MDD, children who have learning disorders). This is a fascinating field and I feel like the psychiatrists I've met actually enjoy going to work. I won't lie, the fact that psychiatry is less competitive than neurology is also a plus (though the difference in competition may be negligible).
 

splik

Professional Cat at Large
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Nov 30, 2009
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well it sounds like you are interested in psych. there is little overlap between neurology and psychiatry and the fields expand and continue to become more divergent. Most neurologists would rather gouge their eyes out than do psychiatry and the feeling is mutual. I am actually interested in behavioral neurology but I could care less about peripheral nervous system problems, stroke etc etc. also it won't make you less competitive having COMLEX only but your score on that exam does matter. obviously getting a crappy USMLE score isn't going to help you any, and programs that insist on the USMLE won't want you even if you have done it (and tbh I know of no programs that it insist on it so it's not commonly required or the programs that do are forgettable). neurology applicants do have higher board scores but it is a fairly uncompetitive speciality and I'm not sure if you look at applicants per place that neurology is any more competitive than psych. psych cares more about interpersonal and communication skills, and a general interest and commitment to the specialty. Don't worry about gunners - no one likes someone who is trying too hard. but it is important to make your presence know, show an interest, make some jokes, come across as a real person with some personality.

On the inpatient unit when you present daily progress of patients you want a 1 liner about the patient and then overnight events, any PRNs, sleep, behavior, treatment, SI/HI, and plan.. "E.g. this is a 50 year old man with a history of recurrent major depressive disorder and cocaine use disorder, admitted with SI in the context of cocaine withdrawal after breakup with his girlfriend. There were no overnight events. He took 50mg trazodone as a prn and had 5 hours of sleep. He was started on Antabuse 250mg to help with cocaine cravings, and restarted on his bupropion XL 300mg for depression and to help with his cocaine use. He is still expressing suicidal ideation but no longer voicing any intent to commit suicide. Diagnostically it is not clear whether he has a primary depressive illness or a substance-induced depressive disorder. The possibility of a bipolar spectrum disorder cannot be ruled out. Aim to discharge patient to an intensive outpatient addictions treatment program when no longer suicidal."
 
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OP
S
Sep 21, 2014
66
7
Status
Medical Student
Th
well it sounds like you are interested in psych. there is little overlap between neurology and psychiatry and the fields expand and continue to become more divergent. Most neurologists would rather gouge their eyes out than do psychiatry and the feeling is mutual. I am actually interested in behavioral neurology but I could care less about peripheral nervous system problems, stroke etc etc. also it won't make you less competitive having COMLEX only but your score on that exam does matter. obviously getting a crappy USMLE score isn't going to help you any, and programs that insist on the USMLE won't want you even if you have done it (and tbh I know of no programs that it insist on it so it's not commonly required or the programs that do are forgettable). neurology applicants do have higher board scores but it is a fairly uncompetitive speciality and I'm not sure if you look at applicants per place that neurology is any more competitive than psych. psych cares more about interpersonal and communication skills, and a general interest and commitment to the specialty. Don't worry about gunners - no one likes someone who is trying too hard. but it is important to make your presence know, show an interest, make some jokes, come across as a real person with some personality.

On the inpatient unit when you present daily progress of patients you want a 1 liner about the patient and then overnight events, any PRNs, sleep, behavior, treatment, SI/HI, and plan.. "E.g. this is a 50 year old man with a history of recurrent major depressive disorder and cocaine use disorder, admitted with SI in the context of cocaine withdrawal after breakup with his girlfriend. There were no overnight events. He took 50mg trazodone as a prn and had 5 hours of sleep. He was started on Antabuse 250mg to help with cocaine cravings, and restarted on his bupropion XL 300mg for depression and to help with his cocaine use. He is still expressing suicidal ideation but no longer voicing any intent to commit suicide. Diagnostically it is not clear whether he has a primary depressive illness or a substance-induced depressive disorder. The possibility of a bipolar spectrum disorder cannot be ruled out. Aim to discharge patient to an intensive outpatient addictions treatment program when no longer suicidal."

Thank you so much for this! It is truly helpful. I think I get started ok, but then I get into the semantics and start to mumble a little. This gives me a good framework on how I need to convey my notes to my attending.