help...struggling with feeling ok in psychiatry

[hamstergang]

What did OP end up doing?

OP hasn't been back on this site since making his one post starting this thread many months ago.

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[Scrooge1]

Admittedly, you referenced a post from like 10 months ago. I now know more and enjoy a lot more of the world beyond acute crisis psychistry.

Are you a Psych resident? How has your views on psych changed?

 

[Drrrrrr. Celty]

Are you a Psych resident? How has your views on psych changed?

I am not. I am applying however.

I think I realized there are multiple dimensions and specialties within psychiatry proper. Likewise I learned that psychiatry is inherently an awesome field and that we have so much time to sit down and listen to patients and really get a comprehensive understanding of their psychopathology. I also like that I feel like there's a lot of research to be done.

 

[Dharma]

This thread should be on the sticky board. Splik's response is GOLDEN and one I plan to reread from time when a little pick-me-up is called for. help...struggling with feeling ok in psychiatry

Warning, my own personal experience lies ahead:

I hit a bump in the road a few months back during PGY3 with refractory outpatient cases, heaps of end-stage personality dysfunction patients, never-ending streams of paperwork, disability, Rx and PA request BS, MyChart messages, minutes long crisis-no-not-really-a-crisis voicemails, patient family members with unrealistic expectations, etc. The burn was getting the best of me and every day seemed dreaded by dawn and celebrated at dusk. I found myself questioning the field in general or at least my place in it especially when very few seemed to benefit and this mindset percolated through the outpatient resident space.

After some introspection and questions regarding my demonstrated commitment beyond external expectations ("had I fully surrendered to this?") I decided to dive deeper into my studies- psychopharmacology and psychotherapy alike- which at least for me allowed the opportunity to become more curious in those refractory cases (or at least give myself a sense of hope, false or otherwise). I've attempted to convince myself (with some degree of success) that I could be that ONE person that seemingly obnoxious borderline-blackbelt comes across who responds with equanimity and curiosity as opposed to the countertransference precipitated knee-jerk reaction they so often experience.... one that has the power to wear a provider down to a nub if not aware of his own personal stuff. (Makes me think of that scene in the Sopranos pilot episode when Tony spoke of his mother with Dr. Melfi, his psychiatrist: "My dad was tough--he ran his own crew. Guy like that, my mother wore him down to a little nub. He was a squeakin' little gerbil when he died").

A psychotherapy supervisor's comment about being interested and fully-present with our patients also struck a chord and often echoes internally during those moments when that developing psychiatrist spidey sense starts tingling from impending personality-dysfunction "danger." Early on that tingling simply induced my own frustration and feelings of helplessness which only yielded existential strife ("What am I doing working here? Why? For what purpose? No one is getting better!") and pushed me even further from that fertile ground of shared-space necessary for healing. Becoming more mindful of my own internal reaction in the moment and approaching the more difficult cases with the intention of remaining aware and being fully present for my patient has been very helpful; it seems to be an act of mindfulness similar to the noting techniques used during insight training in certain meditative disciplines. (Vipassana worth of look for those who seem interested).

How much all of this will yield from a strictly clinical perspective (i.e. measurable results, remitting patients) or how my endurance will benefit for the long-haul remain to be seen but I find myself looking forward to my work more often and with greater vigor. I simply do not see any other approach for myself. Fully surrendering to the process and going all-in seems to be the only way... for me. "Ain't no such thing as half-way shrinks."

 

[Attending1985]

This thread should be on the sticky board. Splik's response is GOLDEN and one I plan to reread from time when a little pick-me-up is called for. help...struggling with feeling ok in psychiatry

Warning, my own personal experience lies ahead:

I hit a bump in the road a few months back during PGY3 with refractory outpatient cases, heaps of end-stage personality dysfunction patients, never-ending streams of paperwork, disability, Rx and PA request BS, MyChart messages, minutes long crisis-no-not-really-a-crisis voicemails, patient family members with unrealistic expectations, etc. The burn was getting the best of me and every day seemed dreaded by dawn and celebrated at dusk. I found myself questioning the field in general or at least my place in it especially when very few seemed to benefit and this mindset percolated through the outpatient resident space.

After some introspection and questions regarding my demonstrated commitment beyond external expectations ("had I fully surrendered to this?") I decided to dive deeper into my studies- psychopharmacology and psychotherapy alike- which at least for me allowed the opportunity to become more curious in those refractory cases (or at least give myself a sense of hope, false or otherwise). I've attempted to convince myself (with some degree of success) that I could be that ONE person that seemingly obnoxious borderline-blackbelt comes across who responds with equanimity and curiosity as opposed to the countertransference precipitated knee-jerk reaction they so often experience.... one that has the power to wear a provider down to a nub if not aware of his own personal stuff. (Makes me think of that scene in the Sopranos pilot episode when Tony spoke of his mother with Dr. Melfi, his psychiatrist: "My dad was tough--he ran his own crew. Guy like that, my mother wore him down to a little nub. He was a squeakin' little gerbil when he died").

A psychotherapy supervisor's comment about being interested and fully-present with our patients also struck a chord and often echoes internally during those moments when that developing psychiatrist spidey sense starts tingling from impending personality-dysfunction "danger." Early on that tingling simply induced my own frustration and feelings of helplessness which only yielded existential strife ("What am I doing working here? Why? For what purpose? No one is getting better!") and pushed me even further from that fertile ground of shared-space necessary for healing. Becoming more mindful of my own internal reaction in the moment and approaching the more difficult cases with the intention of remaining aware and being fully present for my patient has been very helpful; it seems to be an act of mindfulness similar to the noting techniques used during insight training in certain meditative disciplines. (Vipassana worth of look for those who seem interested).

How much all of this will yield from a strictly clinical perspective (i.e. measurable results, remitting patients) or how my endurance will benefit for the long-haul remain to be seen but I find myself looking forward to my work more often and with greater vigor. I simply do not see any other approach for myself. Fully surrendering to the process and going all-in seems to be the only way... for me. "Ain't no such thing as half-way shrinks."

I like your thinking. It does make me question though to what end. Many med students and undergrads read this forum and are looking for honest apppraisals. If we have to try so hard to make it work is it worth it? Other specialties can just show up, do the work, get results and feel good.

 

[justfolks]

I like your thinking. It does make me question though to what end. Many med students and undergrads read this forum and are looking for honest apppraisals. If we have to try so hard to make it work is it worth it? Other specialties can just show up, do the work, get results and feel good.

Just a patient, but this seems like a little bit of magical thinking in terms of the conclusion that other specialties "get results" and "feel good." They don't, necessarily, and they generally don't have the training to cope with the patient who in addition to what may well be a chronic, untreatable, or unclear medical issue may also have a personality disorder, depression or something else that makes them a "difficult" patient.

 

[Mass Effect]

I like your thinking. It does make me question though to what end. Many med students and undergrads read this forum and are looking for honest apppraisals. If we have to try so hard to make it work is it worth it? Other specialties can just show up, do the work, get results and feel good.

Clearly, you and I had very different experiences on other services.

 

[hallowmann]

I like your thinking. It does make me question though to what end. Many med students and undergrads read this forum and are looking for honest apppraisals. If we have to try so hard to make it work is it worth it? Other specialties can just show up, do the work, get results and feel good.

Grass is greener at its best. Other specialties have to deal with plenty of futility, tough patients, and medical inaccuracies/inefficiencies. The ones that just "show up" aren't the ones that "feel good," nor are they the ones that do right by their patients. Every physician needs to work hard to enjoy at least some aspect of their jobs and has to trust in their limits/the limits of current medical knowledge to some degree just to get through their day.

 

[Attending1985]

Grass is greener at its best. Other specialties have to deal with plenty of futility, tough patients, and medical inaccuracies/inefficiencies. The ones that just "show up" aren't the ones that "feel good," nor are they the ones that do right by their patients. Every physician needs to work hard to enjoy at least some aspect of their jobs and has to trust in their limits/the limits of current medical knowledge to some degree just to get through their day.

I’m comparing my experience to my spouse who works in urgent care or my dad a pediatrician. They both have much more opportunity to solve problems and many non personality disordered appreciative patients. They would both say this as well. Yeah they have difficulties here and there but it’s not the breadth of their work. This is just reality and why psychiatry is very difficult in its own right.

 

[hallowmann]

I’m comparing my experience to my spouse who works in urgent care or my dad a pediatrician. They both have much more opportunity to solve problems and many non personality disordered appreciative patients. They would both say this as well. Yeah they have difficulties here and there but it’s not the breadth of their work. This is just reality and why psychiatry is very difficult in its own right.

Perhaps my viewpoint would be different if all I saw were patients with ASPD or BPD, but my clinics are usually at least 50/50. I get what you're saying, but I guess I don't think its the breadth of psychiatry either. My multiple physician family members and close friends in other fields have plenty to complain about in terms of patients and futility as well, so I guess my experience doesn't feel all that unique.

 

[TexasPhysician]

I’m comparing my experience to my spouse who works in urgent care or my dad a pediatrician. They both have much more opportunity to solve problems and many non personality disordered appreciative patients. They would both say this as well. Yeah they have difficulties here and there but it’s not the breadth of their work. This is just reality and why psychiatry is very difficult in its own right.

Disagree

My med school roommate in peds sees back to back to back viruses all the time. Hydrate and rest. Plenty of well children. Plenty of constipation recommending otc miralax. He can spend the majority of the day reiterating basic care.

ER friend is frustrated all the time. Why are you in the ER for a pregnancy test? Blood pressure is not an emergent issue, go home. Quit sticking things in your orifices. It’s a virus but I need higher press ganey scores so here is an abx to treat nothing.

Every field has its problems.

 

[Attending1985]

I know your posts were not in agreement with me but I see them as supportive of my view on things. In peds, you give reassurance and guidance the problem resolves. All is well and parents are appreciative. In ER, you give the pregnancy test, refer back to primary care, ect. These problems have a definitive answer. Compare that to a patient coming to with common problems in psychiatry (poverty, loneliness, relationship dysfunction, ect). These problems don't have definitive answers and won't get better on their own.

 

[ridethecliche]

Just a patient, but this seems like a little bit of magical thinking in terms of the conclusion that other specialties "get results" and "feel good." They don't, necessarily, and they generally don't have the training to cope with the patient who in addition to what may well be a chronic, untreatable, or unclear medical issue may also have a personality disorder, depression or something else that makes them a "difficult" patient.

That awkward moment when a patient suggests OP is schizotypal.

 

[clausewitz2]

That awkward moment when a patient suggests OP is schizotypal.

Magical thinking != schizotypal, not by a long shot. Cf. Joan Didion.

 

[TexasPhysician]

I know your posts were not in agreement with me but I see them as supportive of my view on things. In peds, you give reassurance and guidance the problem resolves. All is well and parents are appreciative. In ER, you give the pregnancy test, refer back to primary care, ect. These problems have a definitive answer. Compare that to a patient coming to with common problems in psychiatry (poverty, loneliness, relationship dysfunction, ect). These problems don't have definitive answers and won't get better on their own.

Still not true. I do evaluations where I merely provide reassurance that the response is normal. I provide counseling for loneliness, relationship problems, career issues, etc. I provide parental training on behavioral issues. It is quite successful.

The vast majority of my patients experience significant improvements and many go into remission or are cured depending on how you personally view it.

 

[ridethecliche]

Magical thinking != schizotypal, not by a long shot. Cf. Joan Didion.

Twas a joke because 'magical thinking' is one of the step 1/2 buzzwords for schizotypal lol. Haven't read that book, but I loved Slouching Towards Bethlehem. I'll have to pick it up.

Also 100 years of solitude, but that's magical realism.

 

[Attending1985]

Still not true. I do evaluations where I merely provide reassurance that the response is normal. I provide counseling for loneliness, relationship problems, career issues, etc. I provide parental training on behavioral issues. It is quite successful.

The vast majority of my patients experience significant improvements and many go into remission or are cured depending on how you personally view it.

I commend you for providing quality work. I wish this was the standard of care. Things would be different.

 

[Dharma]

I like your thinking. It does make me question though to what end. Many med students and undergrads read this forum and are looking for honest apppraisals. If we have to try so hard to make it work is it worth it? Other specialties can just show up, do the work, get results and feel good.

There seems to be a pervading mentality (fantasy?) amongst those entering medicine of some turnkey ideal (undergrad degree-> MD/DO--> complete residency--> BC--> now just show up and do my thing) whereas in reality the process should never cease until one stops practicing (hence the term). I could see one's "practice" remaining quite superficial (or even detrimental?) without digging deep and fully surrendering to the notion that to reach a truly competent level (forget about mastery) one needs to make this more than a 9-to-5 and instead one's lifework worthy of continued sacrifice... even after/when the system no longer demands it, extrinsically speaking. I would like to think this is the case for all physicians, regardless of specialty, although psychiatry offers (forces?) the opportunity to approach the psychosocial domain in a well-informed intentional manner as means of treatment.

This is a challenging field... one that could make folks miserable if not chosen with a clear understanding of what awaits. My fear is that many students are baited with the relatively friendly work hours (both in residency and beyond) and neon-sign words like 'lifestyle' and 'competitive' being thrown around without understanding the personal and professional demands necessary to achieve success and contentment. The typical medical student experience does not tend to elucidate this truth especially when many may simply compare their 4-6 weeks to the 12 they just had on a demanding inpatient medicine service.

Personally, I did not feel the burn until this year as a PGY3 and part of that being due to actually managing cases on my own (although with the help of great supervision) as opposed to being on inpatient when the attending still captains the ship, even when you're "carrying" your "own" patients. PGY3 is a nice taste of real world psychiatry to some degree and one that you simply won't know first-hand until you're actually there in the thick of it.

I digress, I hope more med students read these forums and realize this is far from a walk in the park. Like you said, to make it work... for our patients and for ourselves... we have to try hard... VERY HARD... and beyond residency at that. Without doing so you are either going to be a $#!++y doctor or a non-content (maybe miserable) one... maybe both.

 

[clausewitz2]

There seems to be a pervading mentality (fantasy?) amongst those entering medicine of some turnkey ideal (undergrad degree-> MD/DO--> complete residency--> BC--> now just show up and do my thing) whereas in reality the process should never cease until one stops practicing (hence the term). I could see one's "practice" remaining quite superficial (or even detrimental?) without digging deep and fully surrendering to the notion that to reach a truly competent level (forget about mastery) one needs to make this more than a 9-to-5 and instead one's lifework worthy of continued sacrifice... even after/when the system no longer demands it, extrinsically speaking. I would like to think this is the case for all physicians, regardless of specialty, although psychiatry offers (forces?) the opportunity to approach the psychosocial domain in a well-informed intentional manner as means of treatment.

This is a challenging field... one that could make folks miserable if not chosen with a clear understanding of what awaits. My fear is that many students are baited with the relatively friendly work hours (both in residency and beyond) and neon-sign words like 'lifestyle' and 'competitive' being thrown around without understanding the personal and professional demands necessary to achieve success and contentment. The typical medical student experience does not tend to elucidate this truth especially when many may simply compare their 4-6 weeks to the 12 they just had on a demanding inpatient medicine service.

Personally, I did not feel the burn until this year as a PGY3 and part of that being due to actually managing cases on my own (although with the help of great supervision) as opposed to being on inpatient when the attending still captains the ship, even when you're "carrying" your "own" patients. PGY3 is a nice taste of real world psychiatry to some degree and one that you simply won't know first-hand until you're actually there in the thick of it.

I digress, I hope more med students read these forums and realize this is far from a walk in the park. Like you said, to make it work... for our patients and for ourselves... we have to try hard... VERY HARD... and beyond residency at that. Without doing so you are either going to be a $#!++y doctor or a non-content (maybe miserable) one... maybe both.

Outpatient really drove home for me the idea that the minute I get comfortable and stop trying to challenge myself and keep getting better as a psychiatrist is the minute I start on the road to sucking at my job. I have seen too many people who peaked in residency, basically, and that ain't gonna be me.

 

[justfolks]

Magical thinking != schizotypal, not by a long shot. Cf. Joan Didion.

Joan Didion was what I was thinking of, not trying to suggest or imply anything else!!

 

[MBBSMOM]

I think especially in psychiatry it’s easy to provide low quality care . Most psychiatrists are doing 15 minute med checks which I don’t think is enough time to provide proper care . Some patients are so complex they need longer appointments . A lot of psychiatrists just see the patient and hand them a prescription . This has led to tons of issues in our field . Such as Axis II conditions being diagnosed as bipolar , schizophrenia.Also patients with Axis II conditions on a benzo ,stimulant and antipsychotic.


I’m unsure how it’s not malpractice to diagnose someone as bipolar when they actually have BPD. Giving meds to borderlines instead of telling them to go to DBT is extremely bad care .

The other problem like the op mentions is our patient population . A lot of people with eating disorder or Axis II disorders don’t want to change their maladaptive behavior. It’s hard to go to work daily and think you’re trying so hard and none of your pts are improving. My first job out of residency was predominantly working in an IP unit where people had ASPD and were their for HI. It took me a year to burn out and quit .

Now I work in a unit for pts who mostly have depression ,anxiety and sud . Which I enjoy I prefer IP work because I can spend a longer time talking with patients . I also do a lot of family sessions with the social worker . This may seem unusual to some . But I want to help my patients as much as I possibly can .

 

[Attending1985]

I think especially in psychiatry it’s easy to provide low quality care . Most psychiatrists are doing 15 minute med checks which I don’t think is enough time to provide proper care . Some patients are so complex they need longer appointments . A lot of psychiatrists just see the patient and hand them a prescription . This has led to tons of issues in our field . Such as Axis II conditions being diagnosed as bipolar , schizophrenia.Also patients with Axis II conditions on a benzo ,stimulant and antipsychotic.


I’m unsure how it’s not malpractice to diagnose someone as bipolar when they actually have BPD. Giving meds to borderlines instead of telling them to go to DBT is extremely bad care .

The other problem like the op mentions is our patient population . A lot of people with eating disorder or Axis II disorders don’t want to change their maladaptive behavior. It’s hard to go to work daily and think you’re trying so hard and none of your pts are improving. My first job out of residency was predominantly working in an IP unit where people had ASPD and were their for HI. It took me a year to burn out and quit .

Now I work in a unit for pts who mostly have depression ,anxiety and sud . Which I enjoy I prefer IP work because I can spend a longer time talking with patients . I also do a lot of family sessions with the social worker . This may seem unusual to some . But I want to help my patients as much as I possibly can .

I would estimate 75% of patients that are referred to me don’t have axis 1 disorders. They are a mix of axis II, self medicating abusive relationships and CD. They have been mismanaged for years by pcps and crappy mental health providers. No wonder there is poor access to psychiatric care. The system is clogged with people who don’t need, wont benefit and will probably just be harmed by medications. No one wants to tell them no including therapists who push them towards meds.

 

[TexasPhysician]

I would estimate 75% of patients that are referred to me don’t have axis 1 disorders. They are a mix of axis II, self medicating abusive relationships and CD. The system is clogged with people who don’t need, wont benefit and will probably just be harmed by medications. No one wants to tell them no including therapists who push them towards meds.

Where are you getting such a poor mix of patients?

 

[splik]

I’m unsure how it’s not malpractice to diagnose someone as bipolar when they actually have BPD. Giving meds to borderlines instead of telling them to go to DBT is extremely bad care .

I dont think you understand what malpractice is. It is a form of negligence in which there is a deviation from the standard of care that leads to harm. prescribing drugs for patients with BPD is the standard of care. even the APA's own guidelines recommend the use of the same medications used in the treatment of bipolar disorder for the various symptom clusters of BPD. telling patient to go to DBT is not treatment. It's just silly. Telling patients anything, particularly ones who are help-rejecting is doomed to failure. Telling them to get a treatment which may not even be readily available may be seen as more negligent than prescribing drugs for these patients (and the vast majority of patients in this country are not able to access a fidelity DBT skills group). It would be considered extremely rare for patients with BPD to receive no meds at all. even if they engage in DBT they will often be on meds and continue on such meds after treatment. Also remember that 1 in 5 pts with BPD have comorbid bipolar disorder.

 

[Attending1985]

Where are you getting such a poor mix of patients?

I work in a poor, rural area. It seems half my patients are in some way related (not joking) and come from multi-generational dysfunction.

 

[Attending1985]

I dont think you understand what malpractice is. It is a form of negligence in which there is a deviation from the standard of care that leads to harm. prescribing drugs for patients with BPD is the standard of care. even the APA's own guidelines recommend the use of the same medications used in the treatment of bipolar disorder for the various symptom clusters of BPD. telling patient to go to DBT is not treatment. It's just silly. Telling patients anything, particularly ones who are help-rejecting is doomed to failure. Telling them to get a treatment which may not even be readily available may be seen as more negligent than prescribing drugs for these patients (and the vast majority of patients in this country are not able to access a fidelity DBT skills group). It would be considered extremely rare for patients with BPD to receive no meds at all. even if they engage in DBT they will often be on meds and continue on such meds after treatment. Also remember that 1 in 5 pts with BPD have comorbid bipolar disorder.

NAMI Honors Dr. Marsha Linehan, The Creator of Dialectical Behavior Therapy | NAMI: National Alliance on Mental Illness
This is what Linehan herself says about medications with BPD. Taper down and off if possible and everybody is over medicated.

 

[Armadillos]

NAMI Honors Dr. Marsha Linehan, The Creator of Dialectical Behavior Therapy | NAMI: National Alliance on Mental Illness
This is what Linehan herself says about medications with BPD. Taper down and off if possible and everybody is over medicated.

No disrespect to Dr Linehan but should be no surprise someone who invented/marketed a treatment is likely to promote said treatment. Not saying it’s bad advice to limit meds to what’s necessary in BPD, but just like you should take a grain of salt with recs from psychiatrists closely tied to pharma you have do the same with those who package psychotherapy concepts.

 

[Attending1985]

No disrespect to Dr Linehan but should be no surprise someone who invented/marketed a treatment is likely to promote said treatment. Not saying it’s bad advice to limit meds to what’s necessary in BPD, but just like you should take a grain of salt with recs from psychiatrists closely tied to pharma you have do the same with those who package psychotherapy concepts.

The evidence base for DBT in BPD is very solid. Medications not so much and lots of harm with antipsychotics, stims, Benzos that are used.

 

[MBBSMOM]

I dont think you understand what malpractice is. It is a form of negligence in which there is a deviation from the standard of care that leads to harm. prescribing drugs for patients with BPD is the standard of care. even the APA's own guidelines recommend the use of the same medications used in the treatment of bipolar disorder for the various symptom clusters of BPD. telling patient to go to DBT is not treatment. It's just silly. Telling patients anything, particularly ones who are help-rejecting is doomed to failure. Telling them to get a treatment which may not even be readily available may be seen as more negligent than prescribing drugs for these patients (and the vast majority of patients in this country are not able to access a fidelity DBT skills group). It would be considered extremely rare for patients with BPD to receive no meds at all. even if they engage in DBT they will often be on meds and continue on such meds after treatment. Also remember that 1 in 5 pts with BPD have comorbid bipolar disorder.

The standard of care for BPD is DBT. I do prescribe meds for people with BPD who also have a co morbid Axis I condition. The only med that I seen evidence for that is effective in bipolar and BPD is lamictal. Anti-psychotics aren't shown to be effective in treating BPD. I live in an area where DBT is widely accessible. So I sometimes forget that DBT isn't widely accessible in some places.

 

[clausewitz2]

I dont think you understand what malpractice is. It is a form of negligence in which there is a deviation from the standard of care that leads to harm. prescribing drugs for patients with BPD is the standard of care. even the APA's own guidelines recommend the use of the same medications used in the treatment of bipolar disorder for the various symptom clusters of BPD. telling patient to go to DBT is not treatment. It's just silly. Telling patients anything, particularly ones who are help-rejecting is doomed to failure. Telling them to get a treatment which may not even be readily available may be seen as more negligent than prescribing drugs for these patients (and the vast majority of patients in this country are not able to access a fidelity DBT skills group). It would be considered extremely rare for patients with BPD to receive no meds at all. even if they engage in DBT they will often be on meds and continue on such meds after treatment. Also remember that 1 in 5 pts with BPD have comorbid bipolar disorder.

But if we can't just invoke a magical acronym and banish them from our presence, however will we summarily reject them without feeling bad about it?

 

[Mad Jack]

So I'm currently a PGY3 at a psychiatry program in the Midwest, and doing well resident-wise, along with some research projects. I always was interested in psychiatry but open to other fields, and did have a decent bit of difficulty deciding between psych and neuro (liked the concreteness and knowledge base in Neuro). In intern year, I had some indecision regarding psych while doing inpatient medicine, but it didn't bother me too much.

However, now, for some reason, it's been bothering me a good deal lately. I feel like I'm not really contributing to anything *that* useful with psychiatry and wondering if I should go into a field like EM,surgery, critical care, where I feel like I can more use my knowledge and "do something" and help save lives more directly. It bothers me that in psychiatry, we can prescribe a medication/therapy, have it not work, and that this is not a big deal - just try something else. Patients can miss appointments or not go to follow-up care, and they'd be fine - this isn't true in CC or surgery or some cases of EM. Also my hubris is acting up and I feel like I will "know" more in other fields (e.g. need to understand lab results, read an MRI, or figure out the best abx tx), rather than just having vague ideas of dx that vary provider to provider and purely medication based knowledge . Sure we need to work up other "medical" causes of psychiatric disorder, but this is the exception.

Now, logically, I know that DALY-wise, psychiatry is definitely important. And I definitely see psychiatry vastly improving the quality of life of patients. I'm definitely interested in the field and love the research. I'm also fairly sure that if I switch I will have something to complain about whatever I switch into, and that sometimes the acute cure is not the long-term "cure". But I still am bothered that psychiatry is not as critical to know things (yes you might provide suboptimal care but the immediate dangerousness of this is low, in general). It kills me when half my patients don't show up to clinic ("did they even need me at all?" or "am i even useful to them?"). And I recognize that psychiatry is really not that many hours of training compared to other specialties - which kinda points out that the knowledge base can not truly be that greatly necessary if you don't require as much training time.

I could just not complain and make money, which would be fine except I don't really feel fulfilled by this. I don't mind working hard and definitely could learn more about psychiatry - I just have a hard time seeing the utility. I'm talking with a therapist - but its not really helping. I thinking about this way too much - like 1-2 hours per day and it's in the back of my mind a lot. Not sure where I'm going with this, but did anyone have similar experiences/thoughts and what did you do to get rid of it?

tldr; feel psychiatry is not very helpful to anyone. Advice?

You must have a pretty functional patient base. I feel like if a good number of my patients miss their meds and appointments they end up on the inpatient unit

 

[Attending1985]

But if we can't just invoke a magical acronym and banish them from our presence, however will we summarily reject them without feeling bad about it?

Why is it a rejection if you can’t offer appropriate care?

 

[clausewitz2]

Why is it a rejection if you can’t offer appropriate care?

As @splik noted above, pharmacotherapy is not inappropriate in many cases of people with BPD. Similarly, a general psychiatrist operating according to GPM principles can actually do quite well - there is a fair amount of empirical evidence suggesting non-inferiority in comparison to more expensive/involved/specialized therapies. There is a sampling issue in interpreting this literature, as I think the people likely to make it to a high fidelity DBT team, especially in a research setting, are probably not entirely representative of the average person who gets this diagnosis, but it remains the case that seeing the letters "BPD" = "DBT or GTFO".

Now if you are in a setting where you are only going to be seeing someone every three months for 15 minutes at a time, probably yes you want to refer that person on.

 

[Attending1985]

As @splik noted above, pharmacotherapy is not inappropriate in many cases of people with BPD. Similarly, a general psychiatrist operating according to GPM principles can actually do quite well - there is a fair amount of empirical evidence suggesting non-inferiority in comparison to more expensive/involved/specialized therapies. There is a sampling issue in interpreting this literature, as I think the people likely to make it to a high fidelity DBT team, especially in a research setting, are probably not entirely representative of the average person who gets this diagnosis, but it remains the case that seeing the letters "BPD" = "DBT or GTFO".

Now if you are in a setting where you are only going to be seeing someone every three months for 15 minutes at a time, probably yes you want to refer that person on.

Where I practice when BPD is diagnosed is generally not disclosed to the patient and they are put on numerous medications for symptom management. These patients are not abandoned but overtreated.
Unfortunately I am often on the receiving end getting these BPD patients after receiving inadequate care for many years. Psychiatric care only for BPD is substandard and in reinforces Externalization. Too many psychiatrists because of their own narcissism think they can help these patients when they lack the skills and resources.They don’t get better they are on numerous medications that compromise their health and it’s really sad. If you look at the research on BPD the prognosis is not bad much better than other psychiatric disorders with a good chance of recovery If they get good treatment. Another problem is many people equate BPD with patients I don’t like and it’s misdiagnosed. Narcissistic personality disorder and dependent personality disorder are ones I very often see misdiagnosed as BPD.

 

[clausewitz2]

Where I practice when BPD is diagnosed is generally not disclosed to the patient and they are put on numerous medications for symptom management. These patients are not abandoned but overtreated.
Unfortunately I am often on the receiving end getting these BPD patients after receiving inadequate care for many years. Psychiatric care only for BPD is substandard and in reinforces Externalization. Too many psychiatrists because of their own narcissism think they can help these patients when they lack the skills and resources.They don’t get better they are on numerous medications that compromise their health and it’s really sad. If you look at the research on BPD the prognosis is not bad much better than other psychiatric disorders with a good chance of recovery If they get good treatment. Another problem is many people equate BPD with patients I don’t like and it’s misdiagnosed. Narcissistic personality disorder and dependent personality disorder are ones I very often see misdiagnosed as BPD.

I mean much of what you are saying is true, especially about diagnostic clarity. That is something you can certainly give all the categories of patients you are talking about. Discuss the prognosis, phenomenology, theories about how it comes about. Emphasize that they should see a therapist but that doesn't mean you're going to abandon them.

Don't overtreat. Talk about how the meds never seem to help for very long and you're going to do something very different together, that you are going to work with the patient to figure out which specific medications are doing what and get to the point where those are the only medications the patient is taking. Explain why benzos are not going to be one of those medications.

Just because you are seeing someone as a psychiatrist does not mean you have to increase the dose or add a medication every time they come into your office.

I've said it before, but lean into the medical model of "BPD is a heritable condition that gets better" and act like it. Be a bit more directive in a positive direction. Don't freak out when they mention feeling suicidal and go into crisis mode if that's not unusual for them.

Read Gunderson, there is nuance to it and experience is really helpful but it is not actually rocket science. The most recent GPM handbook is like 160 pages and half of those are examples. It's probably not going to do the trick for people who are self-harming constantly in a fairly serious way or making a dozen suicide attempts in a year but that is also a tiny minority of people who can be conceptualized as BPD.

My inclination for dealing with NPD and DPD is probably to discuss the phenomenology and impact it is having on their lives without speaking the name of the disorder right away, but I admit it's not my area of expertise and reflects somewhat my dislike for the reification of personality dysfunction as a medical condition. BPD is a little different because supplying a more positive identity can be so salutary.

 

[Blanky]

This thread should be on the sticky board. Splik's response is GOLDEN and one I plan to reread from time when a little pick-me-up is called for. help...struggling with feeling ok in psychiatry

Warning, my own personal experience lies ahead:

I hit a bump in the road a few months back during PGY3 with refractory outpatient cases, heaps of end-stage personality dysfunction patients, never-ending streams of paperwork, disability, Rx and PA request BS, MyChart messages, minutes long crisis-no-not-really-a-crisis voicemails, patient family members with unrealistic expectations, etc. The burn was getting the best of me and every day seemed dreaded by dawn and celebrated at dusk. I found myself questioning the field in general or at least my place in it especially when very few seemed to benefit and this mindset percolated through the outpatient resident space.

After some introspection and questions regarding my demonstrated commitment beyond external expectations ("had I fully surrendered to this?") I decided to dive deeper into my studies- psychopharmacology and psychotherapy alike- which at least for me allowed the opportunity to become more curious in those refractory cases (or at least give myself a sense of hope, false or otherwise). I've attempted to convince myself (with some degree of success) that I could be that ONE person that seemingly obnoxious borderline-blackbelt comes across who responds with equanimity and curiosity as opposed to the countertransference precipitated knee-jerk reaction they so often experience.... one that has the power to wear a provider down to a nub if not aware of his own personal stuff. (Makes me think of that scene in the Sopranos pilot episode when Tony spoke of his mother with Dr. Melfi, his psychiatrist: "My dad was tough--he ran his own crew. Guy like that, my mother wore him down to a little nub. He was a squeakin' little gerbil when he died").

A psychotherapy supervisor's comment about being interested and fully-present with our patients also struck a chord and often echoes internally during those moments when that developing psychiatrist spidey sense starts tingling from impending personality-dysfunction "danger." Early on that tingling simply induced my own frustration and feelings of helplessness which only yielded existential strife ("What am I doing working here? Why? For what purpose? No one is getting better!") and pushed me even further from that fertile ground of shared-space necessary for healing. Becoming more mindful of my own internal reaction in the moment and approaching the more difficult cases with the intention of remaining aware and being fully present for my patient has been very helpful; it seems to be an act of mindfulness similar to the noting techniques used during insight training in certain meditative disciplines. (Vipassana worth of look for those who seem interested).

How much all of this will yield from a strictly clinical perspective (i.e. measurable results, remitting patients) or how my endurance will benefit for the long-haul remain to be seen but I find myself looking forward to my work more often and with greater vigor. I simply do not see any other approach for myself. Fully surrendering to the process and going all-in seems to be the only way... for me. "Ain't no such thing as half-way shrinks."

Great post!

 

[Armadillos]

Just because you are seeing someone as a psychiatrist does not mean you have to increase the dose or add a medication every time they come into your office.

This is a super important fact that for some reason doesn’t get appreciated by some residents. I have a patient with schizophrenia I see every month or two for “medication management”. The last half year or more patient has not been on any meds because several factors pushed the risk/benefit ratio to favor no meds. That doesn’t stop me from seeing her at same frequency as it is very helpful to the patient/family and insurance has no issue with billing as I’m considering meds at each visit and document the clinical reasoning.

 

[Scrooge1]

I am not. I am applying however.

I think I realized there are multiple dimensions and specialties within psychiatry proper. Likewise I learned that psychiatry is inherently an awesome field and that we have so much time to sit down and listen to patients and really get a comprehensive understanding of their psychopathology. I also like that I feel like there's a lot of research to be done.

What did you end up doing? Curious to know

 

[Drrrrrr. Celty]

What did you end up doing? Curious to know

I ended up in IM. And aside from a general dislike of icu call I'm pretty happy. Looking back my biggest regret was not dual applying and ending up closer to home because in the end this is a job. Psych was just to say the very least an easier job that required far less work to be proficient at.

 

[TheaterOfTheme]

One thing to bear in mind is that residency programs tend to attract the most intractable and trainwreck patients who are not actually representative of patients in the "real world"- they represent the tail end in terms of level of personality pathology and general complexity. it is also likely that your program just isn't that great. which means you will need to seek out your own additional training/learning or consider fellowship training in particular areas at a better institution.

I routinely look at and request all sorts of labs on patients, looking at imaging including MRI, FDG-PET, DaT etc, and teach my students and residents how do this this and what various findings mean. The number of disorders that can present with altered mental status, psychosis, personality, cognitive, emotional or other behavioral changes is in the tens of thousands. the true diagnosis is often missed.

also comparing outpatient psychiatry to critical care or EM is just ridiculous. of course outpatients, by definition, do not require the acuity of care that is life-or-death. it is not the same kind of patient population. if you were working with conditionally released patients, i can assure you it would be a big deal if one of your patients who had killed someone/committed some sort of violent crime in the throes of their psychosis did not turn up for their appt. but it is true there aren't really any emergencies in psychiatry. that said, i had the opposite experience of finding my patients needed me too much and were too dependent on me.They would attempt suicide or end up in the ER, or become hysterically blind etc if I went away on vacation. This is one reason I do not currently have any patients. I found it too stressful to be so relied upon when I am away quite a bit. Also I dont like doing prior-auths and refills and all that BS.

here are some psychiatry secrets:

• you can't treat patients you don't like.
• patients will vote with their feet.
• most patients aren't ready for change and engagement.
• it is okay to terminate with patients who you don't like or who aren't benefitting from your services, in order to care for patients who will benefit.

psychiatry as a specialty is a race to the bottom. this is unfortunate, but the reality is that there is a HUGE amount to psychiatry and it is not possible to learn it all or even most of it in residency. there are a lot of intricacies to psychopharmacology that most residents do not learn. there are a large number of neuropsychiatric syndromes, inborn errors of metabolism, and behavioral neurological syndromes that go undiagnosed and undetected because you don't learn about it. there are a large number of different psychotherapeutic modalities and it is not possible to master any of them during residency. there are a large number of psychological theories that help us formulate patients that you don't learn about that enrich your understanding of inner mental life and developing treatment plans. psychiatry has a rich social basis and the social and structural determinants of mental health are very important to patient care that is woefully neglected if not deliberately ignored in almost every residency program. there are complex ethical and philosophical aspects of psychiatry that come to the forefront in certain settings (e.g. C/L, forensics) that thinking about enriches our appreciation of the complexities of the field.

I think you have to figure out if it is really psychiatry that is not for you and to jump ship, or whether you are just not liking how it is currently practiced where you are right now. The former is more difficult to navigate. you are damaged goods as a psych resident, so it is not like it will be easy for you to switch specialties. then there is the question of how competitive you are and if you did well enough during your intern months to get strong letters of recommendation from medicine etc, and whether you would be able to go back to being an intern again, and do all the additional years of training for something like pulm/cc or whatever.

On the other hand, if you don't like how things are, you need to work to be the best that you can. You should read widely and voraciously, attend conferences and trainings to learn more about different areas, go bug the neuroradiologists to do wet reads on imaging for your patients, choose electives and areas that help you develop your knowledge and skill base more (for example neuroradiology, behavioral neurology, movement disorders, sleep medicine, neuropsychology, pain medicine, interventional psychiatry, medical genetics would all be interesting and relevant enriching experiences). You could then choose to do a fellowship in something somewhere better (e.g. C-L, pain, sleep, neuropsychiatry, headache, movement disorders, forensics etc) to further hone or develop your skills. Once you are out in practice you can create the kind of job that you like.

Splik, how can I rotate with you?

 

[splik]

Splik, how can I rotate with you?

It depends - what are you? 1st and 2nd yr med students can shadow me over the summer. Med students from minority backgrounds can come through the APA minority medical students program. We have a sub-I that you could apply to formally through VSAS/VSLO but that is out of my hands (I am the course director, but students are selected by the PD). If you are an IMG, I take exceptional IMGs for an externship. If you are a resident, we would have to figure it out but if your program is okay with it and you can get a california medical license then it can work. If you are an attending, we have a visiting scholars program. PM me to discuss.

Applicants usually need to have a strong CV and 2 strong LoRs. I am particularly interested in students who have a track record of publishing papers etc and are interested in producing/publishing papers.

 

[MedMan80]

I ended up in IM. And aside from a general dislike of icu call I'm pretty happy. Looking back my biggest regret was not dual applying and ending up closer to home because in the end this is a job. Psych was just to say the very least an easier job that required far less work to be proficient at.

This was similar with me, although I wouldn't have been happy doing only IM, I would've wanted to specialize and didn't' want to continue to have to kiss ass through residency to gain a good fellowship, i'm 100% content with psych!

 

[Drrrrrr. Celty]

This was similar with me, although I wouldn't have been happy doing only IM, I would've wanted to specialize and didn't' want to continue to have to kiss ass through residency to gain a good fellowship, i'm 100% content with psych!

I think no matter which way you look at it you've got to kiss ass lol. The amount of my 4th year where I held my tongue that this psychiatrist is giving the wrong psych med or better had utterly no idea what that medical condition is left me often overwhelmed.

I think as a whole I think general medicine is a pretty open field. I'm not opposed to staying within it, though I personally am more leaning towards specialization. As much as I didn't think I'd say it. I'm pretty content I didn't end up in Psych. I think no matter which way I want to beat around the bush, I'll be more able to achieve my dreams easier because of it.