Feeling discouraged as a psychiatrist, switch field?

[Ellaellafan]

Hey guys I'm currently finishing a CL psychosomatic medicine fellowship. After doing my medical school CL rotation I absoluetly knew I would go into psychiatry just for the sake of doing CL and no one, esp my parents, could tell me otherwise. Honestly psychiatry was the absolute last field I ever thought I would choose when starting. Anyways, now I find myself to be transitioning into becoming an attending at an academic institution planning to do some outpt and some CL which was my dream job and I honestly am excited to see how I like it. Where's the problem you ask?... Well for a good while now I've been feeling down wondering if I made the right choice going into psych. I just have those days where I feel people don't respect us as true physicians and get tired of being confused with a psychologist. I feel like I'm not a core part of medicine (just an add on) and actually do miss some aspects of medicine (I guess this is why I'm in CL). I told myself if I'm still unhappy after 2 years then I may consider switching fields. I don't know exactly which field yet... And I'm thinking it's probably not easy to do, esp coming from psych background the more "medical" programs may be hesitant. I'm not sure if it's reassurance I'm looking for. But any comments or advice would be welcomed. Just sad to come all this way and feel like this. Also, another this is I went to med school imagining I would be doing missions work abroad and didn't think through that our services are not really used.

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[nitemagi]

Doctors without borders is actually heavily recruiting mental health leaders, especially psychiatrists, right now. You could be a great asset to them.

 

[Ellaellafan]

Doctors without borders is actually heavily recruiting mental health leaders, especially psychiatrists, right now. You could be a great asset to them.

Thanks for replying. I tried navigating their site but didn't get far. If you have specifics or a link please pass it on. Much appreacted as the missions trip component def has been a hit for me. Thanks.

 

[wolfvgang22]

You may just be having a little burn out. Be careful, the grass isn't always greener on the other side.

 

[Ellaellafan]

You may just be having a little burn out. Be careful, the grass isn't always greener on the other side.

I know. I feel a little bad saying that if we got a little more respect even from colleagues I'd feel great about my choice. I think I need some soul searching to see why I'm letting it bother me so much.

 

[OldPsychDoc]

Soon you'll have more control of your life and more freedom to find your 'niche' within psych. It won't always be like residency/fellowship. My suspicion is that you will gravitate to something satisfying.

 

[MacDonaldTriad]

The lack of respect psychiatrists endure doesn’t weigh that heavily on most of us. I think this is because it isn’t there that much, or we just don’t care. Having said that, if I were to guess where this lack of respect would be the most obvious, it would be as a trainee doing consultations for every other medical discipline there is. Finish up, get out there, then see how you feel. If you still pine for something else, there will be time. I’ll bet you a dollar it will not be necessary.

 

[Ellaellafan]

The lack of respect psychiatrists endure doesn’t weigh that heavily on most of us. I think this is because it isn’t there that much, or we just don’t care. Having said that, if I were to guess where this lack of respect would be the most obvious, it would be as a trainee doing consultations for every other medical discipline there is. Finish up, get out there, then see how you feel. If you still pine for something else, there will be time. I’ll bet you a dollar it will not be necessary.

Yes that's partly where it comes from, although usually when they call us they tend to want to hear what we have to say, it's also just culturally even from general population how we're viewed. That being said I do have hope I may feel differently in the future. I think it's about being confident and believing and in what I do. Your comment was reassuring. Thanks.

 

[mpdoc2]

Hey guys I'm currently finishing a CL psychosomatic medicine fellowship. After doing my medical school CL rotation I absoluetly knew I would go into psychiatry just for the sake of doing CL and no one, esp my parents, could tell me otherwise. Honestly psychiatry was the absolute last field I ever thought I would choose when starting. Anyways, now I find myself to be transitioning into becoming an attending at an academic institution planning to do some outpt and some CL which was my dream job and I honestly am excited to see how I like it. Where's the problem you ask?... Well for a good while now I've been feeling down wondering if I made the right choice going into psych. I just have those days where I feel people don't respect us as true physicians and get tired of being confused with a psychologist. I feel like I'm not a core part of medicine (just an add on) and actually do miss some aspects of medicine (I guess this is why I'm in CL). I told myself if I'm still unhappy after 2 years then I may consider switching fields. I don't know exactly which field yet... And I'm thinking it's probably not easy to do, esp coming from psych background the more "medical" programs may be hesitant. I'm not sure if it's reassurance I'm looking for. But any comments or advice would be welcomed. Just sad to come all this way and feel like this. Also, another this is I went to med school imagining I would be doing missions work abroad and didn't think through that our services are not really used.

As a cancer doctor I can tell you all physicians are getting less respect in this day and age. If respect is what you're after, just being a doctor won't garner respect no matter what field you're in.

 

[Ellaellafan]

As a cancer doctor I can tell you all physicians are getting less respect in this day and age. If respect is what you're after, just being a doctor won't garner respect no matter what field you're in.

Thanks, always interesting to hear the perspective of other fields. Maybe I meant relative respect .

 

[WhatUpDoc!]

I know. I feel a little bad saying that if we got a little more respect even from colleagues I'd feel great about my choice. I think I need some soul searching to see why I'm letting it bother me so much.

Yeah, respect for physicians has definitely taken a nosedive since the internet/Dr. Google/Wikipedia-expert age has dawned upon us. But yes, doing some introspective detective work on your part might get to the bottom of why this might be causing you to second guess your career choice. I'm just taking a shot in the proverbial dark here, but I feel like there might some more deep-seated reasons why you may be considering switching to another field (like as you previously mentioned, missing some of the more "medical" aspects of practice). The hate/disrespect/condescension for the mental health field in general will likely not improve within the next 2 years, so if you are basing your decision solely off this factor, then I believe your decision (for a career change) has already been made.

It might be useful to think about all those things that got you initially excited about the field in the first place. Re-read your personal statement from residency. Think back to some patients who you really helped and felt good about as you successfully treated their psychopathology. If it's truly burnout that is the reason you are feeling the way you feel, being reminded of why you do what you do can be a powerful motivator to persevere through a rough patch in your training/career.

I can tell you I was in a similar boat 2 years ago and I ultimately decided to change fields, but this decision came only after heavy discussion with family/loved ones and after I truly evaluated the source of my dissatisfaction with my current practice (in my case I always found myself drawn more to the talking/listening/counseling aspects of medicine rather than procedural/get my hands dirty type stuff, hence why I'm starting a 2nd residency in psych this year)!

Anyways, hang in there and hope you get some insight/revelation about which path you should take!

 

[splik]

Thanks, always interesting to hear the perspective of other fields. Maybe I meant relative respect .

I know what you means. No other field gets shat on as much as psychiatry. You get more exposure to this as a CL psychiatrist which in itself is not for the faint hearted. A great CL psychiatry service is hated, or even reviled, and still readily consulted. The purpose of a good psychiatric consultation service is to be a receptacle for powerful, sometimes murderous feelings that other services have towards their patients, and the metabolize and neutralize these feelings so patients actually get good care. Consulting psychiatrists services can also be idealized and rapidly devalued because we often cannot perform the magic that is expected of us. We can't make patients have procedures we don't have. We can't force people to go live in places we don't want to. We can't find housing for patients. We won't transfer delirious patients to our service. We won't transfer psychotic patients who need acute medical care to our service. In short, we won't collude with the disavowal or magical thinking, or enact projections that come from consulting services. And it can be hard to sit with these feelings if you don't reflect on where they are coming from or what your role is.

I was once referred to as the "psychology resident" in one of the IM residents notes in the HIV clinic as was thinking wtf - you do realize psychiatrists go to medical school too?
I also saw a request for consultation documented in a note as "psycho team to see patient". Really? Psycho team
My absolute favorite consult request was "will you please send someone to do psychiatry on this patient".

But the fun of CL psychiatry is the actual liaison part which tends to be minimized by the demands on the service but is the most important part. Developing a good working relationship with your colleagues in other specialties, creating realistic expectations of what we can and cannot do, managing expectations, decoding the real reason for the consult request can all help.

Yes, it's narcissistically injuring to not be respected as some services, but you have to make peace with the fact that the world we live in privileges technical solutions to problems and that's not how we roll.

I also don't think it is a good idea to switch specialties unless you figure out exactly what it is you would want to do. It's also important to realize most people (even in medicine) are not passionate about what they do, and that's okay. It's very lucky to absolutely love what you're doing and to sustain that throughout one's career. I think there is enough diversity within psychiatry that you can find something that you enjoy.

 

[smalltownpsych]

What's funny is that I don't like being referred to as a psychiatrist either. I wonder if Optometrists and Opthamologists feel that way? There is a lot of stigma toward our patients and it rubs off on us. I tend to be a rebel and like to rage against the machine so I relish battling the stigma most days.

 

[Merovinge]

I know what you means. No other field gets shat on as much as psychiatry.

I was consulted by a medicine team to "clarify" a pt's psychotropic regimen. When asked what the pharmacy had stated and what the question was, I was literally told "Oh we thought you would call the pharmacy and let us know". Certainly takes the rest of psychiatry training to deal with such absurd/devaluing consults in a respectful manner.

 

[nitemagi]

http://www.doctorswithoutborders.or...ho-we-need/licensed-mental-health-specialists

http://www.doctorswithoutborders.org/issue/mental-health

 

[sunlioness]

Favorite consult requests from residency.

On a printout:
Body location: Head
Reason for consult: issues.

----

Said to me by a nurse: "We need to know if this patient is a junky so we consulted the junky doctors."

I found myself wanting to say, "It's the psychiatry service, not the psychic service" a lot.


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[smalltownpsych]

The last couple of consults for medical patients I had were because the patient was being difficult and the nurses were frustrated with them. The hardest part of these is the expectation that I will do something. Although usually I do use my strong interpersonal skills and knowledge of relationship dynamics to smooth everything out and everyone os happy. One aspect of the dynamic to watch for is one that is very similar when working with kids and parents. The staff or parents want us to make the patient or kid behave a certain way and they will try to direct us to do it the same way that they have been trying that is not working. I get my results by doing something different that will work.

 

[Leo Aquarius]

Your completed training in Psychiatry would be seen as an asset going into another non-surgical field.

 

[Ellaellafan]

Thanks!

http://www.doctorswithoutborders.or...ho-we-need/licensed-mental-health-specialists

http://www.doctorswithoutborders.org/issue/mental-health

 

[Ellaellafan]

What's funny is that I don't like being referred to as a psychiatrist either. I wonder if Optometrists and Opthamologists feel that way? There is a lot of stigma toward our patients and it rubs off on us. I tend to be a rebel and like to rage against the machine so I relish battling the stigma most days.

Haha that's the one thing that makes me feel that our fields mistaken identity issue is not just restriced to us. I'm sure the ophthalmologists get that re optomerists.

 

[Ellaellafan]

Yeah, respect for physicians has definitely taken a nosedive since the internet/Dr. Google/Wikipedia-expert age has dawned upon us. But yes, doing some introspective detective work on your part might get to the bottom of why this might be causing you to second guess your career choice. I'm just taking a shot in the proverbial dark here, but I feel like there might some more deep-seated reasons why you may be considering switching to another field (like as you previously mentioned, missing some of the more "medical" aspects of practice). The hate/disrespect/condescension for the mental health field in general will likely not improve within the next 2 years, so if you are basing your decision solely off this factor, then I believe your decision (for a career change) has already been made.

It might be useful to think about all those things that got you initially excited about the field in the first place. Re-read your personal statement from residency. Think back to some patients who you really helped and felt good about as you successfully treated their psychopathology. If it's truly burnout that is the reason you are feeling the way you feel, being reminded of why you do what you do can be a powerful motivator to persevere through a rough patch in your training/career.

I can tell you I was in a similar boat 2 years ago and I ultimately decided to change fields, but this decision came only after heavy discussion with family/loved ones and after I truly evaluated the source of my dissatisfaction with my current practice (in my case I always found myself drawn more to the talking/listening/counseling aspects of medicine rather than procedural/get my hands dirty type stuff, hence why I'm starting a 2nd residency in psych this year)!

Anyways, hang in there and hope you get some insight/revelation about which path you should take!

That is very helpful thanks. Need to re-ignite the passion.

 

[Ellaellafan]

I know what you means. No other field gets shat on as much as psychiatry. You get more exposure to this as a CL psychiatrist which in itself is not for the faint hearted. A great CL psychiatry service is hated, or even reviled, and still readily consulted. The purpose of a good psychiatric consultation service is to be a receptacle for powerful, sometimes murderous feelings that other services have towards their patients, and the metabolize and neutralize these feelings so patients actually get good care. Consulting psychiatrists services can also be idealized and rapidly devalued because we often cannot perform the magic that is expected of us. We can't make patients have procedures we don't have. We can't force people to go live in places we don't want to. We can't find housing for patients. We won't transfer delirious patients to our service. We won't transfer psychotic patients who need acute medical care to our service. In short, we won't collude with the disavowal or magical thinking, or enact projections that come from consulting services. And it can be hard to sit with these feelings if you don't reflect on where they are coming from or what your role is.

I was once referred to as the "psychology resident" in one of the IM residents notes in the HIV clinic as was thinking wtf - you do realize psychiatrists go to medical school too?
I also saw a request for consultation documented in a note as "psycho team to see patient". Really? Psycho team
My absolute favorite consult request was "will you please send someone to do psychiatry on this patient".

But the fun of CL psychiatry is the actual liaison part which tends to be minimized by the demands on the service but is the most important part. Developing a good working relationship with your colleagues in other specialties, creating realistic expectations of what we can and cannot do, managing expectations, decoding the real reason for the consult request can all help.

Yes, it's narcissistically injuring to not be respected as some services, but you have to make peace with the fact that the world we live in privileges technical solutions to problems and that's not how we roll.

I also don't think it is a good idea to switch specialties unless you figure out exactly what it is you would want to do. It's also important to realize most people (even in medicine) are not passionate about what they do, and that's okay. It's very lucky to absolutely love what you're doing and to sustain that throughout one's career. I think there is enough diversity within psychiatry that you can find something that you enjoy.

You're right. Total opposite reactions to psych, sometimes seen as just an add-on but other times people REALLY do respect our decisions and won't budge to another decision esp because medical legal aspect and how much the word of psychiatry means. Also respected when a psych code happens on a med unit and they don't know how to deal with it.

 

[OldPsychDoc]

I think if we focused our energies on BEING the kinds of psychiatrists we want people to think of when they hear the word 'psychiatrist', instead of grousing about what 'they' think of us, we would be happier, and the world would be a healthier place.

 

[doctorpilgrim]

CL psychiatry is harder than general psychiatry because the expectation-reality gap is too high and time period to provide results is too short.
For the OP- it can get easier with more autonomy,more experience and developing relationships with other services in the hospital.

 

[Ellaellafan]

Thank you to everyone who replied. You gave me a lot to think about. Much appreciated.

 

[JKinSC]

I know. I feel a little bad saying that if we got a little more respect even from colleagues I'd feel great about my choice. I think I need some soul searching to see why I'm letting it bother me so much.

I'm on the opposite side of psychiatry training from you (start residency this summer), but has this been a problem everywhere you go? At my institution, psych is pretty well respected, and I made it a point to ask about its standing in everyone of my residency interviews. I'd be lying if I said I was surprised at how many places said they were kind of marginalized as physicians, but there were a few where the residents/attendings said they were completely happy. Is there any chance things could be improved with a simple change in scenery?

 

[twospadz]

I know. I feel a little bad saying that if we got a little more respect even from colleagues I'd feel great about my choice. I think I need some soul searching to see why I'm letting it bother me so much.

People in general do respect you. Your making a 6 figure salary. Your in the 99% in terms of salary in the world. Who cares if giants look down upon you? There are millionaires who complain how billionaires look down upon them. If you let this bother you, you will never be happy. You need to put yourself in your patient's shoes who are actually stigmatized by the people around them. Everyone has something to complain about and there is always someone who will have a more legitimate case than you.

 

[JKinSC]

Doctors without borders is actually heavily recruiting mental health leaders, especially psychiatrists, right now. You could be a great asset to them.

This is great to hear! I'd honestly given serious thought to DWB entering med school, but when I decided on psych I thought that might have passed me by. I just assumed that they'd be far more interested in EM/IM types.

 

[Ellaellafan]

I'm on the opposite side of psychiatry training from you (start residency this summer), but has this been a problem everywhere you go? At my institution, psych is pretty well respected, and I made it a point to ask about its standing in everyone of my residency interviews. I'd be lying if I said I was surprised at how many places said they were kind of marginalized as physicians, but there were a few where the residents/attendings said they were completely happy. Is there any chance things could be improved with a simple change in scenery?

I think it's a general attitude, but hopefully somehow will be diff in a diff scenario. I guess I mean it's not just doctors but pts too.

 

[Ellaellafan]

People in general do respect you. Your making a 6 figure salary. Your in the 99% in terms of salary in the world. Who cares if giants look down upon you? There are millionaires who complain how billionaires look down upon them. If you let this bother, you will never be happy. You need to put yourself in your patient's shoes who are actually stigmatized by the people around them. Everyone has something to complain about and there is always who will have a more legitimate case than you.

True! Thx

 

[deleted380846]

Deleted

 

[nitemagi]

In the same boat as OP. Wondered if I dissociated and posted this myself. Part of this in me comes with the mixed feelings I have about being done with training. Happy to be done, but as a medical student I thought there would be some shift when I became an attending. Maybe I would know more or being able to do more? Turns out that I am still me. I am waiting to see how things play out before switching careers. Good luck.

I'd encourage the idea of lifelong/longitudinal learning. Therapy learning included. You've had those times, probably where you realize "hey, I actually know a lot of stuff." There's some further transformative moments when you can look at a difficult situation that others are stumped by and say "I have three ways of understanding and working with this that others don't." We are all works in progress, but there's clear progress towards "mastery" that I do not believe really happens in residency. You can get good at meds and superficially proficient at a therapy or two. But there's more to the road, my friends.

 

[Wilf]

I just have those days where I feel people don't respect us as true physicians and get tired of being confused with a psychologist. I feel like I'm not a core part of medicine (just an add on) and actually do miss some aspects of medicine

A psychiatry attending in my program was recently panicking over a CK value of 200.

 

[SomeDoc]

Have you thought about taking some time off before starting as an attending? It could be as little as a week to a month off and it may be helpful. Also I'm surprised that it hasn't been mentioned in this thread yet, but have you considered seeing a therapist?

 

[F0nzie]

Keep ignoring the naysayers. They are never going to go away. Unfortunately your passion in CL forces you to work with medical staff that only know how to use half of their brain. Take some time off and surround yourself with people outside of work that have your best interests at heart.


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[MacDonaldTriad]

Within psychiatry there are some truly outstanding psychiatrists and there are some remarkably unimpressive psychiatrists. Strive to be truly excellent and you will gain the respect of those who see it and there is nothing you can do about those who do not look for talent. Changing specialties will not make you any more or less impressive than who you already are. Psychiatry is a deep enough endeavor to challenge the limits of human capability and brain surgery isn’t rocket science anyway.

 

[freudianslipp]

When I told a patient recently that I'm going into psychiatry, she responded with "wow, you must really like feet". Yes, Psychiatry and Podiatry both start with a P and end with "iatry". oy vey!

 

[Attending1985]

I can relate too. Especially to the part about ability to work abroad. Never thought I'd care about this but it does bother me feeling like I've lost the true physician identity. Wish I would've done a combined residency and had more career flexibility.

 

[sunlioness]

I'm a true physician. F-- that noise. You went to med school, didn't you? I'll show you my license. It says "Medical Physician & Surgeon". That's what I am.


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[Attending1985]

I think we've all struggled with our limitations in helping people in psychiatry. That doesn't bother me as much as the worry that I'm causing iatrogenic harm whether it be with medications or diagnostic labels. I understand that people need help now and we know very little but it sill gets to me and makes me wonder about switching fields.

 

[deleted343839]

I get mistaken for a physician all the time, in part because I am one psychologist in a department of medical subspecialists. Talk about respect.

You can apologize for your existence, or you can name the problem with clear eyes and do your work regardless of your non-psychiatrist colleagues' knowledge deficits and unprofessional behavior.

I remember the first time I p*ssed off a referring physician because I refused a consult after she was unable to articulate a coherent referral question or even a clear goal for my seeing the patient. All I knew was that I was being called in at the sad tail end of a long journey with a challenging patient, and I wasn't about to shoot myself in the foot when the team was already preparing to transfer the patient to another facility. That incident informed my rallying cry: if you want me on your team, I'm yours. If you want a dumping ground, find someone else.

Find an environment where you are a respected member of the team most of the time, and the stupid calls will roll off your back more easily. You are so much more than an "add-on."

 

[mpdoc2]

I get mistaken for a physician all the time, in part because I am one psychologist in a department of medical subspecialists. Talk about respect.

You can apologize for your existence, or you can name the problem with clear eyes and do your work regardless of your non-psychiatrist colleagues' knowledge deficits and unprofessional behavior.

I remember the first time I p*ssed off a referring physician because I refused a consult after she was unable to articulate a coherent referral question or even a clear goal for my seeing the patient. All I knew was that I was being called in at the sad tail end of a long journey with a challenging patient, and I wasn't about to shoot myself in the foot when the team was already preparing to transfer the patient to another facility. That incident informed my rallying cry: if you want me on your team, I'm yours. If you want a dumping ground, find someone else.

Find an environment where you are a respected member of the team most of the time, and the stupid calls will roll off your back more easily. You are so much more than an "add-on."

I'm surprised by how many people on this forum are getting insulted when people confuse them for psychologists.

 

[Blitz2006]

I'm on CL Service right now.

For the most part, the service is well respected in the hospital. Maybe this is an anomaly? I always laugh at the small minority who question our "medical skills", particularly the medicine guys.

I tell them that honestly, the vast majority of our drugs that we prescribe are far more "dangerous" (Lithium, VPA, Clozaril, Risperdal, Haldol, Benzos, etc.) than the vast majority of drugs that medicine hospitalists prescribe (e.g. Protonix, Norvasc, Statins, Metformin, etc).

I dunno, one of the things I love about Psych is that it has a little bit of everything (some inpatient, some consult, some patient interaction, some outpatient, some pharmacology/prescribing, some neuroanatomy/neuroimaging). Unlike fields like Rads/Path which have 0 patient interaction, 0 prescribing or fields like derm which have relatively little anatomy.

 

[Leo Aquarius]

Got a buddy in Rads going into IR where there's lots of patient contact. Derm has pathophysiology on their side. Psych doesn't have any. What's the pathophysiology of epidermolysis bullosa? That's right.

What's the pathophysiology of depression? Say what?

Yep.

 

[hypoman]

Who cares what the pretentious "real docs" think. If anything I use this as a screening tool for who I want to be friends with and associate myself with. If someone is too short sighted and rude to respect you for being a psychiatrist then they're not worth you're time. I pride myself with the idea of going into a field that truly interests me and has the chillest schedule of any medical field.

Screw em. Let them hate.

 

[PikminOC]

I was consulted by a medicine team to "clarify" a pt's psychotropic regimen. When asked what the pharmacy had stated and what the question was, I was literally told "Oh we thought you would call the pharmacy and let us know". Certainly takes the rest of psychiatry training to deal with such absurd/devaluing consults in a respectful manner.

But it churns the rvus

 

[Blitz2006]

Got a buddy in Rads going into IR where there's lots of patient contact. Derm has pathophysiology on their side. Psych doesn't have any. What's the pathophysiology of epidermolysis bullosa? That's right.

What's the pathophysiology of depression? Say what?

Yep.

Sure, but my point was Psychiatry has a variety of interests, not just a sole field. Maybe not pathophysiology, but whats the psychopharmacology of depression ? Or the neuroanatomy of cocaine addiction?

I realize Breast/IR have patient contact, but I meant for most DR guys. Especially since next year DR and IR are going to be separate matches.

I just finished my on call, and we had an interesting patient, in 70s with visual hallucinations for a few months. Medical team obviously consults us, we ordered labs, including TSH (patient seemed to have some cognitive impariment, constipation, etc.) . Turns out TSH is 30! Myxedema Crisis. My attending and I did some reading and it looks like patient has hypothyroid induced psychosis!

Pretty cool, and the reason why I love psych

 

[nancysinatra]

Hey there - I think it's interesting how a lot of people responding to your post are honing in on the "respect" thing. I get that, and agree that you should look beyond that. But if it persists, then maybe there’s more to it. It doesn’t mean you’re a bad person just because you “care” how you are perceived within the larger world of medicine. Maybe it just means you want to be a decent doctor. Conscientious health care providers ought to care how their specialty is regarded by the rest of the medical profession, right?

It is possible to choose the wrong specialty. Only you can know. But I don't agree with the idea that you should only change fields if there is one other exact thing you want to do. You should switch if you want to switch, and that’s about all. It's your life, and you need to use your own priorities in deciding.

You mentioned that psychiatry was the last field you ever thought you would choose when you started med school. I am in the same boat. (And I am changing fields.) I wasn’t interested in psych when I started med school. My interests were anesthesia, EM, surgery, or certain IM subspecialties. And I wanted to do something international.

So it makes no sense that I went into psychiatry! But the reason I did was sort of like what you’re saying about C/L. In my case I liked the psychoanalytic concepts I was introduced to in my med school psych clerkship. (I hadn’t yet learned that it takes 7 extra years or so to become an analyst and that analysis is not at all in demand.) I liked learning about eating disorders and personality disorders OTHER than borderline (because I’m not interested in suicide, and suicide attempts are the defining feature of BPD). I actually thought I could contribute to society by helping to cure some of these irrational conditions, many of which cause great havoc to humanity! (Such as NPD, or paranoid PD…). The key word is “cure.” Well, it took me four years of residency to learn that no one besides me is actually hoping to “cure” these conditions. PDs are poorly understood, and their prognosis remains horrible. In a way they are like neglected tropical diseases, like leishmaniasis. I wish someone had told me this 8 years ago!!!

The other thing that interested me was the rarer conditions, like dissociative fugue and political brainwashing. I’ve been doing psychiatry for over 7 years now, and I’ve never seen a case. Instead, I spend my days doing “suicide risk assessments,” because that is where the field is going.

But I didn’t quit right away, and I'm mostly glad. I have worked for a few years now, and learned a lot about about what I want. I’ve made a dent in my loans. I think I’ve helped people even if I don’t go home at the end of the day marveling at the latest depressed person whose life I changed by switching them from Effexor to Cymbalta.

Maybe you'll work for a couple years and decide you love C/L. Or maybe not. It might help to take a bit of time in an unpressured work setting to try to figure that out. Eventually you will figure out what you need to do. Good luck!

 

[splik]

I just finished my on call, and we had an interesting patient, in 70s with visual hallucinations for a few months. Medical team obviously consults us, we ordered labs, including TSH (patient seemed to have some cognitive impariment, constipation, etc.) . Turns out TSH is 30! Myxedema Crisis. My attending and I did some reading and it looks like patient has hypothyroid induced psychosis!

I have seen several patients (n=6) with with myxedema coma with psychopathology and in all of them the TSH was >100. Also in all but one case the raised myxedema coma was caused by psychiatric disturbance rather than the myxedema causing the psychiatric disturbance (of course they can also interact and I've seen that). Visual hallucinations in someone aged 70 might suggest delirium, but as this has gone on for a few months I would certainly consider the possibility of an underlying problem like late paraphrenia, lewy body dementia, or a substance-induced cause. a TSH of 30 is not all that impressive and although if there were other features that suggested significant decompensation (for example hypothermia, heart failure) due to hypothyroidism one might consider that the TSH is an issue. It usually takes several months before cognitive slowing improves with T4 to complicate things further. Although it is certainly possible that the patients psychiatric symptoms were due to hypothyroidism, it would be a mistake to chalk it up to that and not keep an open mind about the differential at this point. Particularly if the patient has a history of hypothyroidism - I would be very much inclined to think that there was something going on that caused the patient to stop taking her synthyroid and leading to this state. In addition although we are all told to think of hypothyroidism in dementia workup, and it can definitely cause cognitive slowing (quite dramatic in fact) the best evidence suggests it is usually an innocent bystandard when present in the context of cognitive impairment and should not blindside the clinician to another cause.

 

[Blitz2006]

Yeah patients temp is around 95 and has a defribillator.

Lewy body is also on top of our differential.

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