Feel like I'm not learning much as an intern - Advice needed

[yanks26dmb]

I'm an intern at a mid-tier, University program with lots of funding, etc, i.e. this isn't for lack of facilities. We have some big names on our faculty and our attendings are from other noteworthy institutions.

I've done three months of inpatient psychiatry to this point and I just feel like my day to day is pre-rounding on patients, writing notes, not doing much of formal presenting, then re-rounding and re-interviewing the patient with the attending. I don't get much critique of my notes, so I can only assume I'm doing okay there? I also feel like I'm not really getting much teaching during the days in general. Are we just expected to learn by watching? Should I be doing more outside reading? Is this common during inpatient months at other programs?

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[Sushirolls]

You need to be proactive and ask the attendings.

"Hey, Doc Boss, I put down mild constricted on the MSE, but I almost put down blunted. Could you help me understand if I'm reflecting on this right?"

"Dr. Awesome But Quiet, my differential for the patient included Schizoaffective, Bipolar Type over Bipolar I, MRE manic with Psychosis. You agreed with my plan for Bipolar as the diagnosis, could you help me understand why this patient isn't Schizoaffective?"

etc.

Keep asking quesions until you start to notice work isn't getting done, the attending is getting annoyed, or you are getting the same answers and you've tapped out that attending.

 

[wolfvgang22]

Is your attending or another attending or senior resident approachable? If so, tell one of them your concerns and seek guidance. Anyone that gets mad because you want to learn is a douche.
I adjust my teaching style and appreciate the feedback whenever students tell me such concerns, and make more time to teach and assign readings. Sometimes we all get too busy. Perhaps you should consider bringing up a recent article or topic of interest and ask your attending for their opinion? Nothing gets my attention as an attending more, in a good way, than enthusiasm and interest in what is going on currently in the field. Examples: Ketamine for refractory Major Depressive Disorder. Treatment of tardive dyskinesia and the new medication recently approved for that, Austedo. Stellate ganglion block for PTSD. Improving access to medications and treatment for patients who have low incomes. If your attending has no interest in any of these and similar topics, he or she is probably burnt out!

 

[adaptation1]

My experience is this. Once you're in residency, a lot of more academic and knowledge-based learning must be self-motivated. The learning on the unit is often of a different nature but equally important -- that is, learning how to work and do the job of a psychiatrist. It's more like trade school. You will find that attendings may evaluate you less on "what you know" and more on "Did I have to cover for his mistakes, again?" and more on "Can I count on him to do the work effectively and accurately?" I remember reading lot of old notes in the system and observing how different attendings document, interview, and relate to staff. Unfortunately, many things that are tested on the PRITE and Boards simply have no bearing in clinical practice. Yet the strongest residents and learners are the ones who can synthesize take their knowledge and use it in a very practical way on the unit. I'm always impressed by this ability.

 

[nitemagi]

Agree with above.

 

[BiscoDisco]

Similar boat as OP. Want to start reading journals, but don't have a lot of money to shell out. Can anyone recommend a particularly good journal or two to start reading?

 

[wolfvgang22]

See what the medical library at your hospital has. They will have most journals available online for free through their library portal. It's good to start with the American Journal of Psychiatry (the green journal). I email myself the pdfs for perusal when I'm at home. For light reading I like the Focus life long learning journal and the psychiatric times also.

For quick 5 minute clinically focused reviews I like Uptodate. If you have access to a VA medical library (at any VA hospital, they all have a library), you can get access to Uptodate. Many academic hospital libraries also have Uptodate available. You can download the app on your phone and log in with your hospital email on the go.

 

[Sushirolls]

Similar boat as OP. Want to start reading journals, but don't have a lot of money to shell out. Can anyone recommend a particularly good journal or two to start reading?

Go talk with the hospital librarian. Get their email. You can email them PubMed ID's and they will email you back the PDF of the article.

One librarian for a hospital I am no longer connected to still encourages me to email any ways for articles, and several days later *poof* articles in my email.

 

[whopper]

When I had a teaching position I wanted medstudents to present a patient once a week, residents to present something once a week (outside of clinical care where residents covered all patients, medstudents covered 3 patients each), and we'd spend at least 15 minutes a day, usually around an hour just teaching outside of just getting work done. This is all things being equal. Sometimes there were hell-days where you just had to focus on getting things done, other days that were easy where we'd have much more time to teach.

While I agree with what's been written above, IMHO this also begs to question to me that perhaps some of the attendings don't want to teach or perhaps something about the job is preventing them. E.g. maybe the work environment for that attending is too demanding.

My first rotation my attending was terrible. By the end of the rotation I was terrible cause I didn't have proper instruction. What I learned later on was the attending, who graduated from the same program I did, was considered a terrible resident, and wasn't respected well as an attending by his colleagues, and by the time I was about mid-2nd year the attendings thought I was better than him (they didn't tell me this until I was a chief resident). If you looked at my reviews all of them are stellar minus the first rotation with him.

 

[splik]

Most of your learning will come from your patients. You are probably learning a lot more than you think. However you are supposed to received two hours of supervision per week, one of which should should be individual (this is an ACGME requirement). You need to ask for that time and can use it to discuss cases, your documentation, ethics/legal issues, systems issues, get feedback on your interviewing skills, learn about diagnosis and formulation, psychopharm, countertransference issues, or get career development advice.

Reading is also very important. I would recommend reading my 100 papers in psychiatry (I will be updating shortly), the Maudsley Prescribing Guidelines, Stahl's Essential Psychopharmacology, Fish's clinical psychopathology, The Mental Status Exam in Neurology, and maybe flip through Kaplan and Sadock (the synopsis is fine - the main text is too big to read through).

 

[Armadillos]

I'm an intern at a mid-tier, University program with lots of funding, etc, i.e. this isn't for lack of facilities. We have some big names on our faculty and our attendings are from other noteworthy institutions.

I've done three months of inpatient psychiatry to this point and I just feel like my day to day is pre-rounding on patients, writing notes, not doing much of formal presenting, then re-rounding and re-interviewing the patient with the attending. I don't get much critique of my notes, so I can only assume I'm doing okay there? I also feel like I'm not really getting much teaching during the days in general. Are we just expected to learn by watching? Should I be doing more outside reading? Is this common during inpatient months at other programs?

I think this is a common feeling, personally I feel like if a resident is self aware enough to feel that they may not be learning enough, then more times than not they have learned way more than they think.

Mechanism of learning as a resident is such a departure from your last 20 years of formal education that it seems natural to feel like your “not learning” just because your not sitting in front of a book for hours a day and not getting grades.

 

[Marasmus1]

I feel like knowing psychiatry and providing good inpatient psychiatric care is obviously related but not necessarily correlated. You may know psychiatry exceptional but inpatient management requires very good communication skills, patience, organization skills, interdisciplinary communication, communication with ancillary staff etc.. Your amazing knowledge of literature and guidelines will only help you manage the cases more efficiently. Having said that lacking communication and management skills ( yes including some scutwork as well depending on the facility) is a damn straight path to failure in inpatient psych no matter how strong your clinical foundation is.

We had an attending who consistently failed board exam 10 years in a row and eventually gave up. His psychiatric knowledge is not up to date. However, he was managing almost everything for what the patient needs including but not limited to calling consults, scheduling imaging studies, escorting patients, calling 2-3 collaterals for each cases. He was working until 7 pm while the other attendings were leaving at 5. Consequently, he was awarded as the best attending consequently for 4 years since he started working in the facility.

So you may learn some psychiatry from books, papers etc. But a lot of things, you learn hands on managing these cases day to day.

 

[MacDonaldTriad]

Don't underestimate the value of a good Kaplan and Sadock read. Article reading is clearly the most up to date, but text books summarized years of articles fairly concisely and you would have to read thousands of articles to cover the breath of a good text. You will read articles the rest of your life. If you don't read the text book by the time you take boards, you probably never will. I'm not saying pick up book and start reading from the beginning and keep going until done. When you get a patient with a disorder you haven't treated before, go read the relevant chapter.

 

[NickNaylor]

A lot of learning is self-motivated, but also a big part of the first chunk of residency - for me, much of intern year - was simply learning the mechanics of "being a resident" and actually functioning in a physician role. That was a big enough task that didn't leave much additional time for extensive learning. Once you get that down, you will be able to focus much more on clinical knowledge, why certain treatment decisions are being made, and being able to pick the attending's brain rather than simply worrying about getting all of the work done. I agree that asking questions and trying to learn as much as possible is critical, but that is also much more easily done once you have a firm grasp on the basics of being a psychiatrist and the mechanics of doing basic tasks such that those aren't occupying most/all of your time.

 

[PsychApp777]

The biggest reason why you’re not learning is because your teaching faculty aren’t teaching. You’re holding up your end of the deal (writing all notes, answering all pages, placing orders, organizing most everything, etc.). In exchange for you doing these tasks (i.e what would comprise the attending’s job in any other setting) the attendings are expected to teach you (no, this does not mean telling you to read... it means explaining, in detail, the rationale for their decision making, giving necessary theoretical background, helping you to make connections, etc.). 95% of teaching faculty don’t hold up their end of the deal because they can get away with it, and they’re at the point in their careers where they’ve already been taken advantage of as residents, so they figure they deserve to coast now. Also, the psychiatrists who are currently old enough to be attendings are, for the most part, much less accomplished than current psych residents, so many don’t feel comfortable teaching (you can’t teach what you don’t know well). The program admin/hospital doesn’t care as long as the documentation is completed and no one dies. You won’t hear this perspective much on this board because most people on here are either faculty themselves, or are residents who identify with the aggressor.

 

[psychapp121]

The biggest reason why you’re not learning is because your teaching faculty aren’t teaching. You’re holding up your end of the deal (writing all notes, answering all pages, placing orders, organizing most everything, etc.). In exchange for you doing these tasks (i.e what would comprise the attending’s job in any other setting) the attendings are expected to teach you (no, this does not mean telling you to read... it means explaining, in detail, the rationale for their decision making, giving necessary theoretical background, helping you to make connections, etc.). 95% of teaching faculty don’t hold up their end of the deal because they can get away it, and they’re at the point in their careers where they’ve already been taken advantage of as residents, so they figure they deserve to coast now. Also, the psychiatrists who are currently old enough to be attendings are, for the most part, much less accomplished than current psych residents, so many don’t feel comfortable teaching (you can’t teach what you don’t know well). The program admin/hospital doesn’t care as long as the documentation is completed and no one dies. You won’t hear this perspective much on this board because most people on here are either faculty themselves, or are residents who identify with the aggressor.

damn

 

[MacDonaldTriad]

The biggest reason why you’re not learning is because your teaching faculty aren’t teaching. You’re holding up your end of the deal (writing all notes, answering all pages, placing orders, organizing most everything, etc.). In exchange for you doing these tasks (i.e what would comprise the attending’s job in any other setting) the attendings are expected to teach you (no, this does not mean telling you to read... it means explaining, in detail, the rationale for their decision making, giving necessary theoretical background, helping you to make connections, etc.). 95% of teaching faculty don’t hold up their end of the deal because they can get away it, and they’re at the point in their careers where they’ve already been taken advantage of as residents, so they figure they deserve to coast now. Also, the psychiatrists who are currently old enough to be attendings are, for the most part, much less accomplished than current psych residents, so many don’t feel comfortable teaching (you can’t teach what you don’t know well). The program admin/hospital doesn’t care as long as the documentation is completed and no one dies. You won’t hear this perspective much on this board because most people on here are either faculty themselves, or are residents who identify with the aggressor.

You could save a lot of words by just putting up your hand and just say "OK boomer". I think the more balanced perspective is that the learning contract is both well done and poorly done about equally on both sides in most places. There is variation among both faculty and trainees of course, but there is also a dynamic that tends to let both sides be disappointed in the other to an exaggerated degree. Don't be passive, read, become confused about something and bring it to your teachers with an honest "can you help me understand this".

 

[PsychApp777]

You could save a lot of words by just putting up your hand and just say "OK boomer". I think the more balanced perspective is that the learning contract is both well done and poorly done about equally on both sides in most places. There is variation among both faculty and trainees of course, but there is also a dynamic that tends to let both sides be disappointed in the other to an exaggerated degree. Don't be passive, read, become confused about something and bring it to your teachers with an honest "can you help me understand this".

Except, for the most part, it’s not a conflict between generations, so much as it is an asymmetry in the levels of accountability between resident (high) and attending (low), in regards to the exchange I described above. A balanced perspective is irrational in the presence of an imbalance.

That said, I was talking in generalities — of course there are many exceptions to this rule...and my impression is that you’re one of the exceptions. However, I’m willing to bet that if you were to take a survey of residents (not just psych residents) asking how many hours of teaching per week they receive from preceptors, the average would lie somewhere between 0 and 1.

Also, it should be noted that the cost of completing psych residency without much teaching is 100% worth the reward of making a great living while working reasonable hours in an interesting field (after residency). So I’m not really complaining, just taking the opportunity to share an observation that I would never be able to share in real life.

 

[MacDonaldTriad]

We can re-frame this and agree some. I think I can say with reasonable authority that it has always sucked to be a resident. Disappointment is mostly a function of expectations not aligning. There will always be good and bad teachers, but most faculty can see deficits in their students accurately and generally can mention them. Being able to help do something about them is an other matter.