Developing clinical decision making intern year

[Throwawaywoop]

I feel like one of my biggest learning experiences intern year has been getting used to the different aspects of clinical decision making: should a patient be admitted or discharged; after they are admitted, what broad category do they fit into (mood, anxiety, psychosis, substance, personality, some combination thereof, etc); what medications or other interventions might they benefit from, etc. When I lay them out like I just did, it seems like it should be fairly simple, but I feel like in the moment, while I’m conducting the interview or even just afterwards, I still struggle with synthesizing all the information.

For example, while I was on call one day this month, I had a patient who was clearly psychotic and rather distressed by it, and it was disrupting some aspects of her life. Without giving too much info, my first instinct was that she should be admitted, but it wasn’t until I discussed the case with the senior later that I realized she didn’t actually meet the criteria for admission, she was well-connected to outside resources, her life would be even more disrupted by being in the hospital, etc. I feel like all of this should’ve been obvious to me from the get-go. And then there are the cases where, for example, the patient tells you they aren’t suicidal, it was all a misunderstanding, they’re future oriented, euthymic, etc but the collateral reveals a completely different story. How long does it take to develop that instinct and have it be correct? Is it even something you can develop, or do some people just have it better than others?

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[Lunzio]

Fellow intern here - this is what residency is for! Don't sweat it just yet!

 

[st2205]

You will figure this out experientially by doing it a lot. Feeling the way you are feeling now is part of that process. And there is no ah-hah moment. It is more like the slow rising of the sun than the flick of a light switch.

 

[Attending1985]

Another thing you will discover is clinical decision making is extremely variable. Ask ten different psychiatrists and get at least five different answers. You will develop your own style, comfort level and instincts it just takes time. But in the end there is typically not a right answer but simply an answer that you can support with reason.

 

[Throwawaywoop]

Another thing you will discover is clinical decision making is extremely variable. Ask ten different psychiatrists and get at least five different answers. You will develop your own style, comfort level and instincts it just takes time. But in the end there is typically not a right answer but simply an answer that you can support with reason.

Yeah I've definitely seen this already; we've had a few patients on inpatient for whom my attending would say "this patient should never have been admitted," but clearly someone else thought differently. I guess the issue is that when I'm asked "what would you do for this patient?" or "what do you think is going on?" these last few weeks as an intern, I've found myself stuck more often than not. There were even times as a sub-I when I would admit a patient and maybe not quite get their diagnosis, but I could say "here is what I think they need" quite easily. Similarly, there have been a couple times already when a med student on service or on call with me makes an astute observation about a patient that I might never have thought of. Perhaps it's a just function of feeling the weight of responsibility much more this year and therefore being more nervous and second-guessing myself more. I try to tell myself that it's still very early, it'll come with time, etc. but I just get worried that it's coming easier and more intuitively for some than others, and if that's the case, how does one develop a quality like intuition/gut instinct?

I know I probably sound neurotic, and I apologize, but talking about this here is honestly quite helpful.

 

[splik]

As mentioned above dispo decisions have more to do with hospital culture or the approach/comfort level of the individual practitioner than they do of actual clinical inference and this can be hard for junior residents and interns to process.

In terms of diagnostic and clinical formulation of the patient a lot of this depends on having tons of experience to draw upon as well as individual differences in your ability to pick up on cues, your social cognition abilities, your ability to be present with the patient and ability to recognize countertransference and use this diagnostically or clinically.

BTW I consider myself a very skilled clinician and see patients that other psychiatrists don’t know what is going on with for 2nd/3rd/4th/5th opinions... very complex cases. And even I don’t know what to make of every patient or what the right thing to do is. In those cases I consult one or more colleagues for their input too. As an intern the most important thing is you ask for help if you don’t know what to do or make of a particular situation and use that as a learning opportunity. You will find you pick it up. The thing about psychiatry is that you’ll always come across some bizarre situation you’ve not dealt with before even many yrs after training!

 

[Attending1985]

Yeah I've definitely seen this already; we've had a few patients on inpatient for whom my attending would say "this patient should never have been admitted," but clearly someone else thought differently. I guess the issue is that when I'm asked "what would you do for this patient?" or "what do you think is going on?" these last few weeks as an intern, I've found myself stuck more often than not. There were even times as a sub-I when I would admit a patient and maybe not quite get their diagnosis, but I could say "here is what I think they need" quite easily. Similarly, there have been a couple times already when a med student on service or on call with me makes an astute observation about a patient that I might never have thought of. Perhaps it's a just function of feeling the weight of responsibility much more this year and therefore being more nervous and second-guessing myself more. I try to tell myself that it's still very early, it'll come with time, etc. but I just get worried that it's coming easier and more intuitively for some than others, and if that's the case, how does one develop a quality like intuition/gut instinct?

I know I probably sound neurotic, and I apologize, but talking about this here is honestly quite helpful.

The fact that you actually care and are questioning yourself and others means more than any “astute observations” right now. Keep it up and you’ll slowly but surely come into your own. If it makes you feel any better I felt like I didn’t really get it until after residency and I’m still learning.

 

[Throwawaywoop]

Thanks so much for the thoughtful replies. I appreciate your wisdom and insight.

In terms of diagnostic and clinical formulation of the patient a lot of this depends on having tons of experience to draw upon as well as individual differences in your ability to pick up on cues, your social cognition abilities, your ability to be present with the patient and ability to recognize countertransference and use this diagnostically or clinically.

In your experience, do interns who struggle with these particular things at first ultimately get better at them? I think I have pretty good social cognition overall, but I still struggle with some aspects of interviewing; for example, I sometimes try to ask a certain question and end up phrasing it in a way that just doesn't come out right, if that makes sense. I try to be present with my patients as much as I can, but I find it difficult sometimes as I struggle to pull all of the pieces of their stories together. I don't always know what to say to especially difficult, uncooperative patients or how to structure their care. I can barely teach the medical students I work with anything because I feel like I'm still learning how to interview, how to formulate a patient, etc. myself. The first couple times I've tried to run groups, I've not been good at it at all. I'd like to think all of this is normal at this early stage, especially since I'm still figuring out how to operate within a new hospital system (I've got the EMR down, I think, but everything else is still a work in progress), but I have this fear that I'm sucking in comparison to the other interns.

 

[ziggyhope]

Thanks so much for the thoughtful replies. I appreciate your wisdom and insight.



In your experience, do interns who struggle with these particular things at first ultimately get better at them? I think I have pretty good social cognition overall, but I still struggle with some aspects of interviewing; for example, I sometimes try to ask a certain question and end up phrasing it in a way that just doesn't come out right, if that makes sense. I try to be present with my patients as much as I can, but I find it difficult sometimes as I struggle to pull all of the pieces of their stories together. I don't always know what to say to especially difficult, uncooperative patients or how to structure their care. I can barely teach the medical students I work with anything because I feel like I'm still learning how to interview, how to formulate a patient, etc. myself. The first couple times I've tried to run groups, I've not been good at it at all. I'd like to think all of this is normal at this early stage, especially since I'm still figuring out how to operate within a new hospital system (I've got the EMR down, I think, but everything else is still a work in progress), but I have this fear that I'm sucking in comparison to the other interns.

Fourth year here. I think your anxiety/doubts are good at this stage, it will motivate you to improve faster. However, do not let them paralyze you. Remember, you are comparing all of your unedited footage (inner turmoil) to everyone else's highlight reels (outer appearance), you have no idea how much your fellow interns/residents/attendings read, discussed with others, debated internally before they arrived at a decision.
Clinical decision making takes time and experience, and I think risk assessment and appropriate level of care is one of the HARDEST skills to learn in residency. At your stage, you should try your best to make a decision, knowing that you have appropriate supervision (hopefully) so that even if it is "wrong", you will learn from it and patients will not be hurt by the decision.

 

[splik]

In your experience, do interns who struggle with these particular things at first ultimately get better at them?

most interns are abysmal at interviewing patients. clinical interviewing is a skill you will continue to develop not just through intern year and residency but throughout your clinical career. most PGY-2s interviewing skills leave something to be desired too. hell, a lot of attendings don't know how to interview patients. at this point, the most important thing is to not miss out on asking about all the major areas of the history, being able to ask about mood and psychotic symptoms, perform a psychiatric systems review, inquire about suicide and violence etc. Also much more important at this point is being respectful, empathic, compassionate with patients. You should take the opportunity in supervision to ask about interviewing, and also solicit lots of feedback.

 

[Taddy Mason]

most interns are abysmal at interviewing patients. clinical interviewing is a skill you will continue to develop not just through intern year and residency but throughout your clinical career. most PGY-2s interviewing skills leave something to be desired too. hell, a lot of attendings don't know how to interview patients. at this point, the most important thing is to not miss out on asking about all the major areas of the history, being able to ask about mood and psychotic symptoms, perform a psychiatric systems review, inquire about suicide and violence etc. Also much more important at this point is being respectful, empathic, compassionate with patients. You should take the opportunity in supervision to ask about interviewing, and also solicit lots of feedback.

Any books you would recommend on interviewing patients?

 

[WingedOx]

most interns are abysmal at interviewing patients. clinical interviewing is a skill you will continue to develop not just through intern year and residency but throughout your clinical career. most PGY-2s interviewing skills leave something to be desired too. hell, a lot of attendings don't know how to interview patients. at this point, the most important thing is to not miss out on asking about all the major areas of the history, being able to ask about mood and psychotic symptoms, perform a psychiatric systems review, inquire about suicide and violence etc. Also much more important at this point is being respectful, empathic, compassionate with patients. You should take the opportunity in supervision to ask about interviewing, and also solicit lots of feedback.

Honestly this why I stress that volume is both important and a good thing in a residency (and why I roll my eyes at the "attendings should just give the residents the interesting cases" takes on here." You aren't going to get good at interviewing and triaging by doing a lot of both.