Biased views and truths to practice after clerkship

[NJWxMan]

I am completely confused during a period when I should be quite confident in my career endeavors. I completed an outpatient rotation last year in psych. and enjoyed it. However, I recently completed an inpatient sub-I and found it to be quite tedious. The inpatient rotation consisted of 90% schizophrenics (20 patients on the service). I felt like I was getting nowhere with many of the patients and felt like there was a total lack of reality on the floor. I have been interested in psych. for quite some time now; probably much of my medical school career. Any suggestions? Should I do another inpatient or outpatient rotation? I tend to do much better with anxiety, depressive d/o, etc patients, and not so much with psychotic d/o's. Is this realistic, especially when I'm looking to do forensics?

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[Faebinder]

I am completely confused during a period when I should be quite confident in my career endeavors. I completed an outpatient rotation last year in psych. and enjoyed it. However, I recently completed an inpatient sub-I and found it to be quite tedious. The inpatient rotation consisted of 90% schizophrenics (20 patients on the service). I felt like I was getting nowhere with many of the patients and felt like there was a total lack of reality on the floor. I have been interested in psych. for quite some time now; probably much of my medical school career. Any suggestions? Should I do another inpatient or outpatient rotation? I tend to do much better with anxiety, depressive d/o, etc patients, and not so much with psychotic d/o's. Is this realistic, especially when I'm looking to do forensics?

I would say you did enough general psychiatry... if you have to pick then go for an elective in a subspecialty like Forensic, Child, Sleep, Addiction. Make sure you have a good neurology rotation... otherwise that's enough psych before you start residency.

 

[Anasazi23]

Sounds like you may be built for outpatient practice. Don't give up on schizophrenics yet, however. Many are chronic and make relatively little progress. However, a large-enough inpatient unit with good turnover and minimal revolving door crowds will show you how much better we can make these folks when they need our help.

It's not that different compared to say, IM, if you think about it.

 

[NJWxMan]

I would say you did enough general psychiatry... if you have to pick then go for an elective in a subspecialty like Forensic, Child, Sleep, Addiction. Make sure you have a good neurology rotation... otherwise that's enough psych before you start residency.

I guess the real question is: Was I meant to be a psychiatrist? I enjoyed forensics (completely based around consulting attorneys). Will I get crushed in residency during my 12 months of non-stop interaction with pyschotic disorders?

 

[Anasazi23]

I guess the real question is: Was I meant to be a psychiatrist? I enjoyed forensics (completely based around consulting attorneys). Will I get crushed in residency during my 12 months of non-stop interaction with pyschotic disorders?

You won't get crushed. Lots of residents are not built to be inpatient docs. If you know you like forensics, or outpatient, get through the inpatient, learn lots, since outpatient is in some ways, an extension of inpatient. Virtually all residents are burned out of inpatient by the time their tenure on the floors is over. You'll survive like everyone else.

 

[whopper]

I'm not sure what you meant by "lack of reality" on the floor. If you could be more specific I might be able to better answer.

It might've also had been related to the place where you did it. Some inpatient units are better run than others.

Psychotic disorders present with different challenges than the other disorders. You may find your tastes changing. I personally found schizophrenic patients frustrating at first but more & more interesting as I went along in my training.

And as Anasazi said, not all psychiatrists are meant for inpatient. If you loved outpatient, and if you heart stays that way, you will have to whether inpatient in the beginning, but your training will eventually change to outpatient.

 

[Doc Samson]

You've got to take the good with the bad. I was miserable for most of my inpatient experience - hated the milieu, really didn't like being "a part of the treatment team." I got into psychiatry to do CL and gutting out my 9 months of inpatient was well worth it once I was into my CL work as a PGY-3 and 4. As mentioned above, it's a lot like IM - folks who want to be intensivists still have to train in clinic, and folks who want to do outpatient still have to rotate in the ICU.

 

[Chimed]

I was in a similar situation during medical school. I remember going to the PD of psychiatry at my medical school and presenting the same dilemma--I like outpatient, but hate inpatient. He responded with, "Very few psychiatrists like inpatient and most end up in the outpatient, so that shouldn't hinder your decision." I took this advice to heart and settled on psychiatry.

I must say, however, that as a resident doing inpatient psychiatry, I actually have found it very interesting and enjoyable. I still plan on doing outpatient psych, but it has been a better experience then I anticipated.

One thing that has helped with this year on the inpatient months is knowing that in order to be a good outpatient psychiatrist, you need as much inpatient experience as possible. I also found that I can always intentionally find some reason to become more involved in my patients. For example, I either find a way to become empathetic about their situation or find something interesting about their psychopathology. After all, if you really think about schizophrenia and its action on the brain, it is really fascinating! Obviously, these patients have a horrible disease...So, I always try to think about how difficult it must be for them in order to help with my own empathy, or lack there of. Thinking like this has helped a lot with the inpatient experience. Not sure if that would work for you, but it is just a thought...Best of luck with your descision!

 

[MacGFlow]

i really agree with what you said, chimed. i mean, i am doing inpatient right now (as a sub-i) and i definitely agree that it can be more than trying at times. the pathology is so dense in some instances that it's hard to think you can do anything at all, and it wears you out. but then i think about how things are for the person on the other side of the table, and it really brings me around. i know inpatient isn't for me, but i don't for a second doubt that i'll learn (and have learned) tons in the setting.

 

[Faebinder]

I guess the real question is: Was I meant to be a psychiatrist? I enjoyed forensics (completely based around consulting attorneys). Will I get crushed in residency during my 12 months of non-stop interaction with pyschotic disorders?

Inpatient psych hardly represents psych. You rotated in it a lot because they are the bread and butter of psychiatry and you have to at least master that skill if you want to move on to different avenue. It's because inpatient's only teaching advantage is pure volume... you will get to master psychiatry faster because you see more cases in inpatient than anywhere else. So don't sweat not liking it... frankly it's not liked by many psychiatrist. We like to know our patients and it's hard to feel you delivered something when you only have known the patient for 3.7 days... many surgeons have a longer turn over and would envy this sonic discharge speed.

On the other hand you will love Psychosomatic rotations (Consultation liason) as well as outpatient psychiatry... the variety is wonderful. You can even combine the two to get the best of both worlds.

Child/Sleep/Pain/Addiction/Neuropsych/Forensic/Adminstrative/Geriatric all live in their own worlds.

My opinion of forensic psychiatry is so low because I find it hard to be amoral.

Best of luck....