Sep 4, 2015
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Burner account...

I'm a 4th year trying to decide what specialty to pursue in residency. I really have enjoyed my 2 psychiatric rotations thus far. The first was more outpatient and the 2nd was more inpatient. I was a little nervous on inpatient as I've never experienced the environment before but it ended up being much different than I expected and once I got comfortable, it was very enjoyable.

I really enjoyed the psych clinic...I'm definitely more of a clinic person. I liked how the psychiatrists really got to know the patient, down to their most intimate thoughts even. I was really shocked at how much they open up to their psychiatrist compared to other specialties. I also thought the patients were more intriguing compared to physical health patients in other fields since you never knew how a particular patient was going to present. The patients often seemed (at least the ones not there for other reasons) very grateful for the work you were doing for them as well. And the psychiatrists just got more time with their patients. The entire encounter didn't feel as rushed as say family medicine.

However, my hang up with choosing psych is the diagnoses that often seem to differ with each doctor and the current treatments. Of the 2, the treatments are what are making me the most hesitant.

I'm just not sure how comfortable I will be at putting someone on benzos or putting someone on 3-4 different psychiatric drugs at once. It kind of scares/intimidates me and makes me afraid that I will end up harming them rather than helping.

I've never been on a psych drug and there's just something a little intimidating to think that these meds are going to effectively change the personality/mood (for lack of a better term) of the patient. Again, they seem to be very grateful for us doing this and most of the time they seem to improve but from what I've read SSRIs have limited effectiveness and for a lot of meds in psychiatry, the field still isn't sure exactly how they're working in terms of mechanism of action (secondary, accessory pathways that get activated, etc. and the overall physiologic change that occurs). Is my understanding correct on this?

Did any of you have this hesitancy before choosing psych? Will these worries be alleviated once I actually study the pharmacology in-depth during residency? I just want to know that what I'm prescribing is safe and effective and it seems so many questions regarding these drugs are still unanswered as far as exact effects.
 

shan564

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Your concerns will only make you a better psychiatrist. A lot of times, polypharmacy and diagnostic inconsistency occurs because somebody wasn't careful enough to figure things out properly. Most of the time, you can avoid benzos and polypharmacy if you take a good history and identify the actual problem.
 
Mar 7, 2015
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You will become comfortable with prescribing medications safely once you go through residency. It's good that you have a sense of respect for how dangerous medications can be; that will make you a better doctor. I think that the mechanisms of actions for most psychiatric medications are pretty well understood. As far as seeing effectiveness, you probably haven't had the chance to see enough follow up visits in the outpatient setting to see patients improve over time, but I imagine you probably got to see several patients in the inpatient setting who may have decompensated after stopping their meds and ended up in the hospital. Since students typically only spend one month on a rotation, it isn't really enough time to see patients substantially improve with psychiatric treatment. As far as diagnosis is concerned, it is true that some patients may not present with classic symptoms that lead to a clear diagnosis with high inter-rater reliability. An accurate diagnosis depends greatly on having an accurate history, as well as observation of the patient's behavior. Sometimes it may take a great while of observing the patient over time to establish a diagnosis. It's not as black-and-white as you may like it to be.
 
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Monkey House

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You are approaching it with the right attitude - psychiatric medications can really help patients - but if not used well can also cause much harm ( I am looking at you benzos!). Residency will teach you how to use them well - and how to help those patients who come to you on sometimes rather scary combinations. It can be done well and when done well the results are rather impressive. But always keep your healthy respect for them will serve you well.
 

hamstergang

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I'm just not sure how comfortable I will be at putting someone on benzos or putting someone on 3-4 different psychiatric drugs at once.
No one should feel comfortable starting 3-4 psych meds at once because it is the wrong move pretty much all the time. One thing to keep in mind is that you don't have to practice like the worst psychiatrist you've seen. Many people come here saying they're afraid to go into psych because they saw someone practice poorly, but you don't have to practice poorly yourself. You can actually do a good job and help people.

there's just something a little intimidating to think that these meds are going to effectively change the personality
I'm not aware of any medication that can change a person's personality.

I think that the mechanisms of actions for most psychiatric medications are pretty well understood
We know what the drugs do to receptors, for the most part, but we don't know for most drugs how that leads to the desired effect. Even with schizophrenia where we believe dopamine to be the main culprit, the most effective medication affects dopamine the least, which is strange.
 
OP
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Sep 4, 2015
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Thanks everyone for the information. It seems like a general consensus that this feeling is common and helpful before entering residency so I do feel better about it. I find it very interesting and was just a little scared that what I was feeling was a "deal breaker" for entering psychiatry but after reading your opinions, it looks as though my thoughts are pretty normal for where I'm at in training.
 

Shikima

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Here's another way to think about psych and medication management - You'll start one medication at a low dosage and have them come back for repeated visit. This will allow you to bill at a higher rate as you're making changes and it'll be slow as to cause a minimal amount of side effects.

One consideration with the very aggressive approach that hasn't been discussed and hasn't been given benefit of the doubt, the physician felt the impatience by those who come to the office looking for a quick fix and the magic cure.
 

Promethean

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Look at it this way... if people who want to be conservative with medications and use them very judiciously self select out of psych, then that will only leave those who are reckless, overprescribers.

Practice according to your conscience and best judgment. People need psychiatrists like the one you want to become. If it interests you, you can step up and be that person.
 

Nasrudin

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I don't get the false dichotomy of polypharmacy in medicine at large vs polypharmacy in psych.

That's not being special or superior in some vague self-affiriming circle jerk. That's being primitive and beholden to the superstitions of abrahamic religions. Brain alteration is the future of the human race.

Maybe polypharmacy is what works on a particular patient. Maybe it should be reduced. Maybe you can't know until you work with the patient long enough and pay close attention. Clinical work is empirical. It's become vogue to assail it for being such in favor of algorithmic/bureaucratic machinery as somehow so much more elegant. Also, conservatism is not superior in it's own right. I know a conservative clinician who causes chains of havoc with his hesitancy on a crowded inpatient unit.

One should be hesitant about one's hesitancy. One's hesitancy is not of special significance. The lizard and ape brain machinery we struggle against, was hesitant to climb out of trees and start roaming the savannah.