Brief outline of your average week?

[Red Beard]

Psychiatric training seems to open many different practice opportunities, perhaps a more varied array of opportunities than any other specialty. I am wondering if the attendings that post here regularly would be willing to share a little bit about the shape of their practice.

What is an average week like for you?

Thank you for your time in this, and for all the other things you've shared here in the forums!

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[OldPsychDoc]

I'm 50-50 Inpt/Outpt. Spend my mornings in a large teaching hospital, cover 8 beds. Sometimes have a noon lecture for the med students, often a noon admin meeting or grand rounds, etc. 3 afternoons are in a general adult outpt clinic of a multispecialty group--mostly bread & butter depression/anxiety stuff. My other 2 afternoons are psych med consults for our affiliated chem dep program. Most days are 8:30-6 ish, including all my charting, etc. Call is about 4 weekends a year for hospital rounding and the rare phone call (advantages of a large group in an integrated health care system ).

 

[Doc Samson]

I'm full-time employed by a large academic hospital. All my clinical work is CL with an interesting mix of general hospital patients and tertiary/quaternary referral cases of complex neurology/neurosurgery stuff. I run a med school clerkship and the psychiatry rotation for the neurology residents. Days M-F 9:30-6ish, no call, no weekends (but my pager is always on for emergencies). As a department chair I spend a good portion of each week in meetings or "administrating." I also try to squeeze some writing into at least 30-60 mins of my work day.

 

[kugel]

I do Emergency Psychiatry almost exclusively.

I work 12-hr shifts at a county psychiatric hospital in the emergency section. There are 2 psychiatrists per shift. We have complete responsibility for the health/welfare of the 8-15 pts on the unit at any given time. Sometimes, our unit census rises as high as 30, and highest I know was 42 (a very bad day).

We are a free-standing psych hospital with no medical backup of any type on site. Our "crash cart" has O2, mask, BVM, suction, AED, and NO meds. I can get ASA, NitroStat, Ativan (PO or IM) from the regular meds nurse, but that takes 3-10 min. In any sort of medical emergency, we call 911.

Each shift, I re-evaluate 2-4 pts from the last shift, whose clinical picture was expected to change enough to maybe not need admission (usually drug/alcohol intoxication, or chronic condition but might do well enough after 1-2 doses of meds to maybe be able to go home).

I evaluate 8-12 new pt's per shift (~50% known to the system), about 70% are involuntary and often quite angry about that, easily 80% have co-morbid substance use issues, but only ~20% are clinically intoxicated.

From 430pm - 830am, the emergency psychiatrists are also responsible for all the psychiatric inpatients in our hospital, 12 adolescents, 48 "regular" adults, 12 "psychiatric ICU" adult patients.

This all seems to be relatively "normal" for a Psychiatric Emergency setting in an urban/suburban setting > 500k pop'n.

 

[Thorazine]

whats the psychiatric icu?

 

[nancysinatra]

I do Emergency Psychiatry almost exclusively.

I work 12-hr shifts at a county psychiatric hospital in the emergency section. There are 2 psychiatrists per shift. We have complete responsibility for the health/welfare of the 8-15 pts on the unit at any given time. Sometimes, our unit census rises as high as 30, and highest I know was 42 (a very bad day).

We are a free-standing psych hospital with no medical backup of any type on site. Our "crash cart" has O2, mask, BVM, suction, AED, and NO meds. I can get ASA, NitroStat, Ativan (PO or IM) from the regular meds nurse, but that takes 3-10 min. In any sort of medical emergency, we call 911.

Each shift, I re-evaluate 2-4 pts from the last shift, whose clinical picture was expected to change enough to maybe not need admission (usually drug/alcohol intoxication, or chronic condition but might do well enough after 1-2 doses of meds to maybe be able to go home).

I evaluate 8-12 new pt's per shift (~50% known to the system), about 70% are involuntary and often quite angry about that, easily 80% have co-morbid substance use issues, but only ~20% are clinically intoxicated.

From 430pm - 830am, the emergency psychiatrists are also responsible for all the psychiatric inpatients in our hospital, 12 adolescents, 48 "regular" adults, 12 "psychiatric ICU" adult patients.

This all seems to be relatively "normal" for a Psychiatric Emergency setting in an urban/suburban setting > 500k pop'n.

Can I ask why your crash cart is so spartan? Why are there no meds or intubating gear? What if someone had EPS with laryngospasms and appeared to be losing their airway before EMS could arrive?

Speaking of things that should be in psych hospitals, I just thought of what must be the dumbest question ever--I've done 6 months of call at a place that admits a high volume of detox patients and straight up intoxicated patients. And it never occurred to me, nor have I ever heard it mentioned in the psych ward--but isn't there a risk of vomiting and choking among sleeping intoxicated people? Shouldn't they at least have the heads of their beds raised as some sort of aspiration precaution? You can't do that in the beds we have in our psych ward...

Not to change the subject of course, I was just curious.

 

[kugel]

whats the psychiatric icu?

Highest acuity, most likely to act aggressively, sexually, or most at risk of being victimized by other pts. Staffing ratio about 150-200% of that on other units.

 

[kugel]

Can I ask why your crash cart is so spartan? Why are there no meds or intubating gear? What if someone had EPS with laryngospasms and appeared to be losing their airway before EMS could arrive?

As a free-standing psychiatric hospital, we have no docs specializing in ER/IM/intensivists. Most of our nurses have not been in a medical ward in years. Having ACLS meds puts in a position to have to spend tens of thousands per year keeping everyone trained and then (without practice) very likely mis-applying the technology and training. Whether you think that's right or wrong, our admin has decided that it is best to use BLS techniques and call 911. It has worked out fairly well, but we do send pts out to the ER more than I would like. Potentially wasting thousands per year - but avoiding many times that in potential lawsuits.

Speaking of things that should be in psych hospitals, I just thought of what must be the dumbest question ever--I've done 6 months of call at a place that admits a high volume of detox patients and straight up intoxicated patients. And it never occurred to me, nor have I ever heard it mentioned in the psych ward--but isn't there a risk of vomiting and choking among sleeping intoxicated people? Shouldn't they at least have the heads of their beds raised as some sort of aspiration precaution? You can't do that in the beds we have in our psych ward...

Not to change the subject of course, I was just curious.

Most of our pt's are in recliners that don't go completely flat - so that particular issue isn't much problem. However, even flat, aspiration is VERY rarely a signif. issue in the places I've worked. If they are medically unstable, we do send them out to the ER until more stable.
But... it's not that hard to put 2-4 pillows under one end of a mattress to raise it 10-20 degrees. Think simple before you decide you can't practice without a particular piece of equipment.

 

[nancysinatra]

As a free-standing psychiatric hospital, we have no docs specializing in ER/IM/intensivists. Most of our nurses have not been in a medical ward in years. Having ACLS meds puts in a position to have to spend tens of thousands per year keeping everyone trained and then (without practice) very likely mis-applying the technology and training. Whether you think that's right or wrong, our admin has decided that it is best to use BLS techniques and call 911. It has worked out fairly well, but we do send pts out to the ER more than I would like. Potentially wasting thousands per year - but avoiding many times that in potential lawsuits.

Oh I don't really agree or disagree--I was just curious. But this brings up a question I have. I am ACLS certified because my residency requires it. However I'm hardly the person you want running your next code. So let's say a patient on the psych floor codes, and the rapid response team does not show up. I have actually heard of patients dying at psych institutions in the past because of this, what with locked facilities and all. Anyway, say I'm there, with my ACLS card, wondering what to do next. Now I could go ahead and proceed, assuming we have the equipment and medications in the crash cart. If the patient has a bad outcome, will I be responsible for that? Alternatively, if I do nothing--I mean, beyond using BLS skills and assuming they were not helping, that patient might just die. Would I be responsible for not doing ACLS protocol then?

Likewise, if someone goes into anaphylactic shock or something, and again, no help is arriving, is someone like me supposed to pull out the intubation kit and use it? If I don't, am I responsible for that too?

Obviously step one in such situations is to call for help, step two is to wait for help and keep calling, but if help doesn't arrive and the patient is rapidly getting worse, what is the psych resident or attending's responsiblity or duty in a coding or impending airway loss situation when the necessary equipment is at hand in the crash cart and I'm ACLS certified because my program requires it? Since psych units are locked and can be hard to get onto and sometimes just hard for medical teams to even FIND, I can't imagine this has never happened.

But... it's not that hard to put 2-4 pillows under one end of a mattress to raise it 10-20 degrees. Think simple before you decide you can't practice without a particular piece of equipment.

Good idea! I just was curious why I'd never heard of this being a concern. We have so many patients in this condition at the place where I do call. I also predict a pillow shortage if I start putting in text orders that will quadruple the number of pillows alloted to individual patients!

 

[OldPsychDoc]

....
Good idea! I just was curious why I'd never heard of this being a concern. We have so many patients in this condition at the place where I do call. I also predict a pillow shortage if I start putting in text orders that will quadruple the number of pillows alloted to individual patients!

Pretend you're an airline and charge $8 per pillow.

 

[psychotrope]

Likewise, if someone goes into anaphylactic shock or something, and again, no help is arriving, is someone like me supposed to pull out the intubation kit and use it? If I don't, am I responsible for that too?

why in the world would anyone expect a psych resident/attending to intubate someone? Heck there are pgy-3's in medicine who can't do that and nervously wait for anesthesia to come down on their micu months.......

 

[Red Beard]

 

[nancysinatra]

why in the world would anyone expect a psych resident/attending to intubate someone? Heck there are pgy-3's in medicine who can't do that and nervously wait for anesthesia to come down on their micu months.......

Did you read my post? I did not say a psych resident should just go and do this. I asked about cases where help does not arrive. I referred to the situation, for example, if the psych ward is locked (which it always is) and the rapid response team can't get in. I referred also to a case where someone died because of this. It isn't made up. It's a real life case. I guess you just want patients to die rather than have "psych resident/attendings" try anything that they learn in the REQUIRED ACLS courses my residency demands we take? In ACLS, we practiced intubating. What for, given your response? Why did we practice these skills and why was I required to be certified if according to you I should NOT implement the skills even in the case of failure of anesthesia/rapid response to arrive or get through the locked psych unit doors and the impending death of the patient? I am, again, referring to an actual even that happened on a psych ward in the not too distant past. But I assure you, your point is very well taken.

And btw, I would hope such a situation never happens.

 

[nancysinatra]

Oh ha ha ha. I thought it was interesting what Kugel said about his typical week and thought I'd ask more about a particular thing he said, ie the crash cart. I certainly had no intention of derailing someone's bring-your-kid-to-work-day type conversation, which appears to have died on its own. Thanks for your mean picture.

 

[nancysinatra]

Wow. You sound like a joy.

With your 7 posts and MS1 status I'm impressed at how quickly you pegged me, and so correctly at that. But the OP didn't even have the good graces to thank the attendings who answered his question, and who did so at some length, and quite interestingly, I'd like to add.

This thread can now die on its own, I guess. I'm outta here.

 

[Red Beard]

Oh ha ha ha. I thought it was interesting what Kugel said about his typical week and thought I'd ask more about a particular thing he said, ie the crash cart. I certainly had no intention of derailing someone's bring-your-kid-to-work-day type conversation, which appears to have died on its own. Thanks for your mean picture.

Did you make my about you? It was a light-hearted joke. Hence the .

Your dig about my "bring-your-kid-to-work-day" topic, however, is something different.

 

[Red Beard]

With your 7 posts and MS1 status I'm impressed at how quickly you pegged me, and so correctly at that. But the OP didn't even have the good graces to thank the attendings who answered his question, and who did so at some length, and quite interestingly, I'd like to add.

This thread can now die on its own, I guess. I'm outta here.

Who's to say I wasn't waiting for any stragglers before posting my appreciation?

That being said, since we are obviously done with the topic/thread at this point:

OPD, Doc Samson, and kugel: Thank you very much for taking the time to write!

As for you Nancy, un-bunch your panties!

 

[Anasazi23]

I'll try to get this back on topic (veiled warning) by briefly explaining what I do.

I work in a large inpatient forensic hospital. It is situated next to a prison and from the outside, looks itself like a prison, complete with double layered razor wire and perimeter security. It's a maximum security facility.

I treat ITPs (incompetent to proceed) and few NGI / NGRIs (not guilty by reason of insanity) patients. The job is the toughest I've ever had from a clinical perspective, as these are chronic, severely violent, predatory, accused felons who were too psychotic, unstable, delusional, etc, to proceed with trial.

The majority of my patients are on multiple medications - some on 3 antipsychotics at least for a period of time. As much as I hate doing that, many of the traditional augmentation strategies fail, and we have to resort to heroic measures. Needless to say, most of my patients fail monotherapy by definition.

All is not lost, however, as the average time to restore to competency hovers around 90 days. Some, of course, are much easier to treat and stay a much shorter period of time. Others have been admitted for years.

The job is good if you like forensics, and are interested in the true interface between the criminal justice system and psychiatry. Though, the job is also a bit of a blow to your self-esteem, as it's not garden-variety monotherapy treatment response.

One of the toughest aspect of the job is the discovery of the "schizopath." Or, the decompensated schizophrenic, who, after responding to medications, leaves you with the ugly underbelly of severely maladaptive sociopathic tendencies with a smidgen of the remaining psychosis. This leaves for an often ugly, ugly picture.

The job is 8-4, though you often don't get out until later. And believe me, that's about enough time you can spend there, as you yourself are spent after this amount of time. Thankfully, the staff and security are strong, which makes your job easier.

The psychologists do a lot of the leg-work, writing evaluations, and performing tests that I might want to have, such as IQ, personality, or malingering, etc.

I'm about to start a moonlighting job also for some extra money. I haven't decided if this will be private practice, or join a group for now, of which there seem to be quite a few opportunities.

Hope this is helpful.

 

[Red Beard]

...I work in a large inpatient forensic hospital. It is situated next to a prison and from the outside, looks itself like a prison, complete with double layered razor wire and perimeter security. It's a maximum security facility....

This sounds like a very intense environment. It certainly speaks to the variety of practice opportunities in psychiatry. Thanks!

 

[psychotrope]

The job is the toughest I've ever had from a clinical perspective, as these are chronic, severely violent, predatory, accused felons

Though, the job is also a bit of a blow to your self-esteem

One of the toughest aspect of the job is the discovery of the "schizopath."

This leaves for an often ugly, ugly picture.

The job is 8-4, though you often don't get out until later. And believe me, that's about enough time you can spend there,

sheeesh, sign me up! Sounds like the job from hell.

Seriously though, why did you take it? Did you(or want to soon) do a forensics fellowship and that is your passion?

 

[235750]

Thank you to all those physicians who have shared their experiences to us students, it is much appreciated

Anasazi, your job sounds incredibly demanding. I consider working for the NHSC from time to time, but I'm afraid I'll get an assignment like you have. Did you complete a fellowship in forensics?

 

[Anasazi23]

The job is demanding, and yes, I'm formally trained in forensic psychiatry via a fellowship.

The work, however, offers some benefits in that the pay is good, the benefits are strong, the staff is good, and the work is interesting from a psychopathology and academic forensic perspective.