How damaging is being a psychiatrist to your mental health?

[glassesvar]

I’m really interested in psychiatry, but I’ve heard it’s a very emotionally and mentally taxing field. I feel like I’m much more sensitive than the average person, and especially perceptive to other people’s emotions. But I am concerned that these traits will make me more susceptible to being emotionally drained as a psychiatrist.

Psychiatrists, how many of you feel that your job affects your mental health significantly?

Do you feel that being a psychiatrist is worse for your mental health than other specialties?

I’ve heard psychiatrists have some of the highest rates of sucidide and divorce out of the specialties, do you think that is because they chose psychiatry, or that people with mental health problems are more likely to go in to psychiatry and thus the rates are just coincidental?

---

Members don't see this ad.

 

[TexasPhysician]

I very much enjoy my outpatient psychiatry practice. Draining aspects would be dealing with rare staff issues like turnover, but that comes with running any business.

I find “call” in general to be draining, so I don’t do inpatient work.

In med school, I found surgery to be the most draining, especially with long surgeries. Answering medical trivia, retracting, and standing still for hours is for the birds.

Everyone has a different personality that may be negatively affected by different aspects of medicine.

 

[Monocles]

People have different tolerance for things. For example, I loooove working with kids and adolescents and feel energised working on inpatient units just hanging out with the kids and teens all day. Whereas outpatient and with grown-ups drives me completely nuts and makes me miserable af.

Psychiatry is such a wide and different field that you just have to find the population that brings joy when you work with them! Anything from hardcore inner city substance, trauma, etc to high functioning worried well.

OP psychiatry is a great field to consider if you're a med student!

(However if you're not even in med school yet then run far away and do anything else in your life that is not medicine...)

 

[glassesvar]

(However if you're not even in med school yet then run far away and do anything else in your life that is not medicine...)

Why do you say this?

 

[sloop]

Maybe I'm in the minority on this. I absolutely love what I do. I also find what I do to be emotionally draining.

Obviously I don't find the job draining to an extent that I don't want to do it anymore but at the end of a day I'm usually fairly shot, even if it wasn't a particularly long/late day. I'm actually rather introverted and, while I do not dislike talking to people (several attendings have complimented me on my bedside manner and what they've described as a genuine, thoughtful and sensitive demeanor), it actually is not my favorite part of the job. What I look forward to most with a new admission is when I've already interviewed the patient and get to sit back, drink some coffee and dictate a detailed formulation (if I have time). That said, there's a lot of interaction and, if I'm totally honest, calling people on the phone which I hate.

Aside from finding it draining purely from the perspective of an introverted temperament, there is a lot of badness that we see and, as much as we don't like to talk about it (especially with patients), much of that is rather intractable. You wind up picking up the slack for the lack of social and medical infrastructure for people with certain types of problems. Maybe it's just where I'm at, but there are times where it feels like the hospital is full of people diagnosed with "adjustment disorder" but in reality have behavioral sequelae of intractable medical problems that can't be adequately managed elsewhere (epilepsy, massive stroke/post-cardiac arrest, a variety of child-onset neurodevelopmental syndromes, chronic pain with an identified devastating etiology).

On net, I still think this is by far the most enjoyable area of medicine. I truly love this job. I find it fascinating and, in some ways, it is one of the few remaining practical jobs in applied philosophy. It is extremely gratifying to help these patients and I truly feel that I'm giving people back their functional experience of life itself on a daily basis. There are truly draining parts to it, but you have to figure out whether it's worth it. There are draining aspects to every specialty, after all.

 

[ridethecliche]

Why do you say this?

Because it's a long grueling road and everyone says some variation of this to talk folks out of it.

If you love it... stay the course... if you can see yourself doing anything else that's fulfilling to you, then don't. Folks in college see the paychecks that doctors make and don't see the loans, the interest, the lost time for hobbies and investments, and personal sacrifice that comes along with things.

If you have a well thought out reason for doing things then ignore what he said and what I said. He's a resident and I'm an MS4, but I'm going to assume that we're a similar age. I know lots of attendings that are happy and others that are miserable... just like everyone else.

 

[TexasPhysician]

Why do you say this?

Medicine is a grueling road and not financially rewarding for many many years. You have to love it.

Consider my hand surgeon friend:
4 years of med school studying/ working 80 hrs/week (debt + interest) + 7 years residency/fellowship working 80 hrs/week ($50k/year).

Nurse Practitioner wife
3 year masters paid for by working as RN during training.
8 subsequent years making $100k+ for 40 hr weeks.

Engineer friend:
Started at $100k and now at $170k for 11 years post-undergrad with 40 hr weeks. May hit $200k by year 13.

At age 34:
Engineer at about $1.5 million net positive. Had the engineer worked 80 hours like the hand surgeon then it would be close to $3 million.

NP at $800k net positive. $1.6 million working hand surgeon hours.

Hand surgeon at $200k debt.

Starting at age 34ish, the hand surgeon will start catching up with a $400k+ salary. If the engineer worked 80 hours and saved a good % of money with compounding returns, it could take decades to catch up to him.

I really enjoy psychiatry, and I’m really glad I took this path. It was worth it for me, but it wasn’t easy.

 

[nitemagi]

I love what I do, even though I don't do it full time right now.

Part of getting good at doing this is learning how to protect your mental health. Or at least it's supposed to be.

 

[finalpsychyear]

Medicine is a grueling road and not financially rewarding for many many years. You have to love it.

Consider my hand surgeon friend:
4 years of med school studying/ working 80 hrs/week (debt + interest) + 7 years residency/fellowship working 80 hrs/week ($50k/year).

Nurse Practitioner wife
3 year masters paid for by working as RN during training.
8 subsequent years making $100k+ for 40 hr weeks.

Engineer friend:
Started at $100k and now at $170k for 11 years post-undergrad with 40 hr weeks. May hit $200k by year 13.

At age 34:
Engineer at about $1.5 million net positive. Had the engineer worked 80 hours like the hand surgeon then it would be close to $3 million.

NP at $800k net positive. $1.6 million working hand surgeon hours.

Hand surgeon at $200k debt.

Starting at age 34ish, the hand surgeon will start catching up with a $400k+ salary. If the engineer worked 80 hours and saved a good % of money with compounding returns, it could take decades to catch up to him.

I really enjoy psychiatry, and I’m really glad I took this path. It was worth it for me, but it wasn’t easy.

Great post. I might mention I have a friend in a similar engineer position. They also keep climbing up their ladder as well. My friend after 10 years is 3rd from the top in a multi million contracting company and in 10 years one of the 2 above him will retire and i know the top guy makes high 6 figures. So the hand surgeon may actually never catch up to someone who stays in a company for 20-30 years and moves up the ladder.

 

[Dharma]

Why do you say this?

I'm going to keep referring to this thread for a while: help...struggling with feeling ok in psychiatry

I do not think it has much to do with talking folks out of it but rather to help potentials realize that psychiatry can be (WILL BE) a grind regardless of the so-called lifestyle hours. Love it or hate it, it's taxing at times.

May be too late to know you hate it until you're in the thick of it though...

 

[VA Hopeful Dr]

Medicine is a grueling road and not financially rewarding for many many years. You have to love it.

Consider my hand surgeon friend:
4 years of med school studying/ working 80 hrs/week (debt + interest) + 7 years residency/fellowship working 80 hrs/week ($50k/year).

Nurse Practitioner wife
3 year masters paid for by working as RN during training.
8 subsequent years making $100k+ for 40 hr weeks.

Engineer friend:
Started at $100k and now at $170k for 11 years post-undergrad with 40 hr weeks. May hit $200k by year 13.

At age 34:
Engineer at about $1.5 million net positive. Had the engineer worked 80 hours like the hand surgeon then it would be close to $3 million.

NP at $800k net positive. $1.6 million working hand surgeon hours.

Hand surgeon at $200k debt.

Starting at age 34ish, the hand surgeon will start catching up with a $400k+ salary. If the engineer worked 80 hours and saved a good % of money with compounding returns, it could take decades to catch up to him.

I really enjoy psychiatry, and I’m really glad I took this path. It was worth it for me, but it wasn’t easy.

Your hand surgeon friend is woefully under paid.

 

[Dharma]

Maybe I'm in the minority on this. I absolutely love what I do. I also find what I do to be emotionally draining.

Obviously I don't find the job draining to an extent that I don't want to do it anymore but at the end of a day I'm usually fairly shot, even if it wasn't a particularly long/late day. I'm actually rather introverted and, while I do not dislike talking to people (several attendings have complimented me on my bedside manner and what they've described as a genuine, thoughtful and sensitive demeanor), it actually is not my favorite part of the job. What I look forward to most with a new admission is when I've already interviewed the patient and get to sit back, drink some coffee and dictate a detailed formulation (if I have time). That said, there's a lot of interaction and, if I'm totally honest, calling people on the phone which I hate.

Aside from finding it draining purely from the perspective of an introverted temperament, there is a lot of badness that we see and, as much as we don't like to talk about it (especially with patients), much of that is rather intractable. You wind up picking up the slack for the lack of social and medical infrastructure for people with certain types of problems. Maybe it's just where I'm at, but there are times where it feels like the hospital is full of people diagnosed with "adjustment disorder" but in reality have behavioral sequelae of intractable medical problems that can't be adequately managed elsewhere (epilepsy, massive stroke/post-cardiac arrest, a variety of child-onset neurodevelopmental syndromes, chronic pain with an identified devastating etiology).

On net, I still think this is by far the most enjoyable area of medicine. I truly love this job. I find it fascinating and, in some ways, it is one of the few remaining practical jobs in applied philosophy. It is extremely gratifying to help these patients and I truly feel that I'm giving people back their functional experience of life itself on a daily basis. There are truly draining parts to it, but you have to figure out whether it's worth it. There are draining aspects to every specialty, after all.

What PGY are you?

 

[sloop]

What PGY are you?

I'm a PGY-2. Why?

 

[Old&InTheWay]

Why do you say this?

I think many people say this in large part because it feels satisfying to have a narrative of one’s life that says you have done something difficult and overcome adversity. The physicians who have said things like this to me are generally unable to express what they would rather have chosen as a career, or what's holding them back from making a change now.

 

[Evidence Based]

I've personally found the internal medicine and neurology portions of my internship to be much more taxing on my mental health than the psychiatry rotations. Part of this is work hours, but part of it is the reality that caring for sick people (no matter what your specialty) is taxing on your mental health. Psychiatry has its own difficulties, but is not unique.

All of medicine will tax your mental health a little bit. For me psychiatry taxes it the least and gives me the most fulfillment!

 

[TexasPhysician]

Your hand surgeon friend is woefully under paid.

For some insane reason, he decided to take a job in academics.

 

[Liquid8]

If you pursue a career in psychiatry, it is almost guaranteed that you will be exposed to patients who have been through very difficult and disturbing experiences. How one responds to this will determine your suitability for psychiatry, and a lot of doctors who have excluded psychiatry as a career choice will actively try and avoid it – although often failing to realise that working in other areas of medicine is no guarantee, as well as coming with less of the supports and skills needed to really manage things.

Being aware of and perceiving other people’s emotions is a good skill to have, and paying attention to these subtle changes and nuances during an interview should assist in being able to direct questions and conversations especially around sensitive matters. One certainly needs empathy, but sympathise too much and you’ll end up taking on burdens which are not our – this is usually counterproductive and may lead to burnout. If you find yourself getting a bit too involved, one useful piece of advice I was given was to ask yourself quietly from time to time is, “who is the patient?” which should help keep one grounded.

 

[whopper]

I haven't found psychiatry to be more stressful than other jobs. Of course bad things happen in it such as if you have a patient who commits suicide you're going to feel terrible, inaequate, etc for several days, but every field has pitfalls like this.

My wife is a professor in counseling and I find her job more stressful than mine because of the stupid university politics.

The BIG X FACTOR IS.....do you like what you do? I know surgeons that would hate what I do. I would hate the lifestyle of surgery despite that I liked doing surgeries.

 

[MedMan80]

There will be days where it hits you most, but overall the nice hours and "low intensity work", especially if outpatient make it attractive. And of course it helps if you can build the mechanisms to help your own mental health along the way.

 

[whopper]

Didn't remember this until now.
I did have a few jobs I couldn't stand, but these weren't because of the field of psychiatry but because of other factors.

In residency, the nurse in the emergency psych would try to bully the residents and often times there was a weak attending who wouldn't take leadership so I didn't like working there. When I did emergency psych at U of Cincinnati I loved it there cause the attendings, residents, and nurses were all great. Again not psychiatry's fault, it was poor leadership at the other place.

I didn't like geri-psych much cause I had far fewer "wins." I like seeing people get better. Having several patients demented, one after another, was frustrating cause there usually wasn't a way to get the patient more than slightly better. I had a few successes in determining a cause to the patient's problem and reversing what was then thought to be dementia (e.g. hepatic encephalopathy) but those were few and rare. Also several patients committed to the geri-psych unit against their will would often times tell me something to the effect of ,"I'm 95 years old, so what if I don't want to live? I want to go out the way I want to go," and that really didn't sit with me well cause part of me felt that I was taking away their dignity. I didn't get this feeling with younger patients cause I was much more confident I would get them better.

I also didn't like working in a jail but that wasn't cause of psych, it was cause like in any jail it's unsafe, poorly lit, smells like Lysol, several people are bullies from top to bottom and they often times set you up to do poor care (e.g. like spend 2 minutes a patient). There's a reason why if you work in a jail or prison you usually make a heck of a lot more money. Hardly anyone would work there except for the big money. My former employer put me there (it wasn't U of C, it was a different place), paid me what they paid all the other professors, despite that what I did was harder, more dangerous, in terrible conditions, that I was bringing in way more money to the dept than the others, and dept took the rest of the money and put it in their own pocket. The jail it turned out was paying about 3x what I was getting out of it. Not to mention they were doing a heck of a lot of other things wrong but that's another story. Again not the fault of the field itself. It was bad management.

 

[Dharma]

I'm a PGY-2. Why?

I thought that may be the case.

I did not really hit any bumps in the road until a few months into outpatient clinic (for us PGY3). Don't get me wrong, PGY1 and 2 were challenging but in completely different ways and IMO overall less demanding with the exception of hours on the job. Outpatient was the first time I really started feeling the "holy $#!+... no one is getting better... what the F are we doing here" thing.

I did not experience much (if any) of this on CL, inpatient, detox, ED given the relative lack of longitudinal care. There was often a sense of satisfaction come discharge or dispo. I could often tell myself that things would work out for the patient and move on to the next case. The reality of the limitations of our treatments is quite palpable in outpatient and in all honesty it has affected by perspective on the field as a whole (including the worlds of inpatient and CL). Coming to terms with this has been challenging.

Outpatient is a different ballgame IMO. I can agree with mentors of mine who have said it is when one starts to "become" a psychiatrist. (Even those who were not fans of outpatient have mentioned this). The growth is (or should be) exponential however that comes at a price. Outpatient year kind of forces the hand. I wonder how many are truly willing to pay the price or simply say, F it, go through the motions, and become a half-@$$ed psychiatrist. (Let's face it there are plenty of those out there). I can see how easy that could be.

I want students to know how rough it can be. Talk to me a year ago and I would not have had such thoughts. I likely would have been much more optimistic as a PGY1 or 2.

My message is still positive... it CAN be VERY fulfilling... but ONLY if one is ready to fully commit. Those extra "lifestyle" hours everyone talks about need to be spent with your nose buried in a book or else success and satisfaction will likely be low.

 

[Amygdarya]

I thought that may be the case.

I did not really hit any bumps in the road until a few months into outpatient clinic (for us PGY3). Don't get me wrong, PGY1 and 2 were challenging but in completely different ways and IMO overall less demanding with the exception of hours on the job. Outpatient was the first time I really started feeling the "holy $#!+... no one is getting better... what the F are we doing here" thing.

I did not experience much (if any) of this on CL, inpatient, detox, ED given the relative lack of longitudinal care. There was often a sense of satisfaction come discharge or dispo. I could often tell myself that things would work out for the patient and move on to the next case. The reality of the limitations of our treatments is quite palpable in outpatient and in all honesty it has affected by perspective on the field as a whole (including the worlds of inpatient and CL). Coming to terms with this has been challenging.

Outpatient is a different ballgame IMO. I can agree with mentors of mine who have said it is when one starts to "become" a psychiatrist. (Even those who were not fans of outpatient have mentioned this). The growth is (or should be) exponential however that comes at a price. Outpatient year kind of forces the hand. I wonder how many are truly willing to pay the price or simply say, F it, go through the motions, and become a half-@$$ed psychiatrist. (Let's face it there are plenty of those out there). I can see how easy that could be.

I want students to know how rough it can be. Talk to me a year ago and I would not have had such thoughts. I likely would have been much more optimistic as a PGY1 or 2.

My message is still positive... it CAN be VERY fulfilling... but ONLY if one is ready to fully commit. Those extra "lifestyle" hours everyone talks about need to be spent with your nose buried in a book or else success and satisfaction will likely be low.

As they say, psychiatry is easy to do poorly and hard to do well.

 

[sloop]

I thought that may be the case.

I did not really hit any bumps in the road until a few months into outpatient clinic (for us PGY3). Don't get me wrong, PGY1 and 2 were challenging but in completely different ways and IMO overall less demanding with the exception of hours on the job. Outpatient was the first time I really started feeling the "holy $#!+... no one is getting better... what the F are we doing here" thing.

I did not experience much (if any) of this on CL, inpatient, detox, ED given the relative lack of longitudinal care. There was often a sense of satisfaction come discharge or dispo. I could often tell myself that things would work out for the patient and move on to the next case. The reality of the limitations of our treatments is quite palpable in outpatient and in all honesty it has affected by perspective on the field as a whole (including the worlds of inpatient and CL). Coming to terms with this has been challenging.

Outpatient is a different ballgame IMO. I can agree with mentors of mine who have said it is when one starts to "become" a psychiatrist. (Even those who were not fans of outpatient have mentioned this). The growth is (or should be) exponential however that comes at a price. Outpatient year kind of forces the hand. I wonder how many are truly willing to pay the price or simply say, F it, go through the motions, and become a half-@$$ed psychiatrist. (Let's face it there are plenty of those out there). I can see how easy that could be.

I want students to know how rough it can be. Talk to me a year ago and I would not have had such thoughts. I likely would have been much more optimistic as a PGY1 or 2.

My message is still positive... it CAN be VERY fulfilling... but ONLY if one is ready to fully commit. Those extra "lifestyle" hours everyone talks about need to be spent with your nose buried in a book or else success and satisfaction will likely be low.

To be honest, my program is heavily inpatient-focused. In fact, all of second year and much of our third year is not actually outpatient. I’m not really sure I agree entirely about the learning involved in inpatient vs outpatient but that’s a bit beside the point. My hospital is a referral center/psychiatric quaternary care kind of place. About half of the patients (generally on our subspecialty inpatient units) are referrals with long histories of non-response or inadequate response to treatment. These cases are plenty desperate (but also very rewarding in their own ways). In comparison, my outpatients have much more favorable prognoses.

I agree that it’s easy to be a crappy psychiatrist and that it takes hard work to be a good one. A major part of why I chose the program I did was that in comparison to other good programs, I didn’t feel like this one would tolerate someone just skating by. I think that’s turned out to be true, but the other side of the coin is that I feel like I’m working all the effing time (relative to friends in other programs). But everything comes at a price.

 

[NontradCA]

As they say, psychiatry is easy to do poorly and hard to do well.

This is my experience. I’ve met a lot of psychiatrists who aren’t at all emotionally drained because they give zero ****s.

I’ll also add that the road to becoming a psychiatrist just plain old sucks. I’m HOPING it’ll be worth it, but in the middle of the thick of things I’m having doubts. Not gonna quit, obviously, because I’m trapped with debt. If I had a 200k job on the other side I wouldn’t even tell anyone I was quitting. I would just ghost them and never step in a hospital again.

Sincerely,
PGY-1

 

[NontradCA]

I thought that may be the case.

I did not really hit any bumps in the road until a few months into outpatient clinic (for us PGY3). Don't get me wrong, PGY1 and 2 were challenging but in completely different ways and IMO overall less demanding with the exception of hours on the job. Outpatient was the first time I really started feeling the "holy $#!+... no one is getting better... what the F are we doing here" thing.

I did not experience much (if any) of this on CL, inpatient, detox, ED given the relative lack of longitudinal care. There was often a sense of satisfaction come discharge or dispo. I could often tell myself that things would work out for the patient and move on to the next case. The reality of the limitations of our treatments is quite palpable in outpatient and in all honesty it has affected by perspective on the field as a whole (including the worlds of inpatient and CL). Coming to terms with this has been challenging.

Outpatient is a different ballgame IMO. I can agree with mentors of mine who have said it is when one starts to "become" a psychiatrist. (Even those who were not fans of outpatient have mentioned this). The growth is (or should be) exponential however that comes at a price. Outpatient year kind of forces the hand. I wonder how many are truly willing to pay the price or simply say, F it, go through the motions, and become a half-@$$ed psychiatrist. (Let's face it there are plenty of those out there). I can see how easy that could be.

I want students to know how rough it can be. Talk to me a year ago and I would not have had such thoughts. I likely would have been much more optimistic as a PGY1 or 2.

My message is still positive... it CAN be VERY fulfilling... but ONLY if one is ready to fully commit. Those extra "lifestyle" hours everyone talks about need to be spent with your nose buried in a book or else success and satisfaction will likely be low.

This will vary based on your programs patient population. At my place, half (no exaggeration) of our patients use meth and are homeless. The readmission rate is astoundingly high. The only solace I have as far as doing good is knowing I can give them a bed to sleep in. But, yes, it’s draining and annoying. I’m probably burnt out. YMMV

 

[sloop]

This is my experience. I’ve met a lot of psychiatrists who aren’t at all emotionally drained because they give zero ****s.

I’ll also add that the road to becoming a psychiatrist just plain old sucks. I’m HOPING it’ll be worth it, but in the middle of the thick of things I’m having doubts. Not gonna quit, obviously, because I’m trapped with debt. If I had a 200k job on the other side I wouldn’t even tell anyone I was quitting. I would just ghost them and never step in a hospital again.

Sincerely,
PGY-1

I found that intern year really sucked, especially the off service rotations. Some of my lowest moments were stamding around in an ICU, presenting a patient I’d admitted overnight and being pimped about ventilator settings. Another was in the damn neuro ICU when I was writing notes every day about managing popoff pressures for an intraventricular drain. It’s very demoralizing when a good portion of your time is spent on stuff that is 0% relevant to your interests. Then, lots of your on service time is colored by the residual burnout from some of those off service blocks.

At least in most programs, it gets better. Second year has its challenges but at least they’ll generally be challenging in terms of learning things that are relevant to your career (or dealing with the frustrations involved in the types of patients you like to treat).

 

[Dharma]

IIf you find yourself getting a bit too involved, one useful piece of advice I was given was to ask yourself quietly from time to time is, “who is the patient?” which should help keep one grounded.

"The patient is the one with the disease." -The Fat Man

 

[nitemagi]

Avoiding burnout yet staying engaged requires, IMPO, cultivating a state of Detached Compassion. Compassion for the person, and that they're suffering. But detachment from your own satisfaction being tied to a specific outcome. There are difficult cases, ones that try all of our abilities. If we get more invested than the patient, though, then it becomes easy to get burned by them if they don't try or sabotage -- ultimately leading to burnout. Apathy is the equally unappealing extreme, where complete lack of engagement means investing nothing and feeling nothing. It becomes clock punching and nothing else, which means also deriving no satisfaction from the work.

Instead try appropriately, proportionally to the patient's investment, know your limits and when it's taking a toll on you, but try.

 

[Dharma]

This will vary based on your programs patient population. At my place, half (no exaggeration) of our patients use meth and are homeless. The readmission rate is astoundingly high. The only solace I have as far as doing good is knowing I can give them a bed to sleep in. But, yes, it’s draining and annoying. I’m probably burnt out. YMMV

Oh plenty of malingerers in the ED, no doubt. I think we do a pretty good job preventing those from becoming admissions (minus a few typical bleeding hearts who always seem to admit). It was always frustrating seeing the blatant ASPD malingerers with zero interest in actual treatment getting through to the unit. Luckily I also had the chance to work with attendings who would pull the discharge lever within minutes to hours of them hitting the floor. (Well known cases of course). I do not miss seeing these cases on my inpatient census and I still loathe seeing the vast majority of these cases in the ED. I guess there's a nice degree of SUCK just about everywhere in medicine. (That's most jobs too, BTW. Facts Of Life 101, LOL).

This is my experience. I’ve met a lot of psychiatrists who aren’t at all emotionally drained because they give zero ****s.

I’ll also add that the road to becoming a psychiatrist just plain old sucks. I’m HOPING it’ll be worth it, but in the middle of the thick of things I’m having doubts. Not gonna quit, obviously, because I’m trapped with debt. If I had a 200k job on the other side I wouldn’t even tell anyone I was quitting. I would just ghost them and never step in a hospital again.

Sincerely,
PGY-1

Keep grinding; a lot of us have had thoughts similar to your own at some point (that ghosting fantasy is something I've heard from others). Be on the lookout for those facets of the field that particularly interest you, explore it thoroughly, and dive in. Let that become your catalyst. Remember what captivated you from the get-go. It may take time to find that pocket you're looking for but you'll get there; something awaits if you stick it out. For me, the more I read and the more curious/interested I become in my patients the clearer my path is; still working on it though. It makes putting up with the rest of the BS of medicine a helluva lot more tolerable as well.

To be honest, my program is heavily inpatient-focused. In fact, all of second year and much of our third year is not actually outpatient. I’m not really sure I agree entirely about the learning involved in inpatient vs outpatient but that’s a bit beside the point. My hospital is a referral center/psychiatric quaternary care kind of place. About half of the patients (generally on our subspecialty inpatient units) are referrals with long histories of non-response or inadequate response to treatment. These cases are plenty desperate (but also very rewarding in their own ways). In comparison, my outpatients have much more favorable prognoses.

At a similar place myself in regards to the bolded. I also found the revolving door of the inpatient unit disheartening. I did see a lot of "wins" as well though while inpatient, much more than I do in outpatient. I've been told by many (here and from attendings) that academic outpatient psychiatry can entail working with the most refractory of cases and that outpatient can look quite different in the "real world" (whatever that means). Regardless, I'm seeing the benefit with some of those refractory cases even when we do not make med changes. Therapy works, even if during a med management appointment. Late-stage personality dysfunction is challenging AF! I'm a better psychiatrist (in the making) because of these interactions but have a long way to go. How long seems overwhelming to think about, so eyes on today's work, for the most part.

 

[Dharma]

Avoiding burnout yet staying engaged requires, IMPO, cultivating a state of Detached Compassion. Compassion for the person, and that they're suffering. But detachment from your own satisfaction being tied to a specific outcome. There are difficult cases, ones that try all of our abilities. If we get more invested than the patient, though, then it becomes easy to get burned by them if they don't try or sabotage -- ultimately leading to burnout. Apathy is the equally unappealing extreme, where complete lack of engagement means investing nothing and feeling nothing. It becomes clock punching and nothing else, which means also deriving no satisfaction from the work.

Instead try appropriately, proportionally to the patient's investment, know your limits and when it's taking a toll on you, but try.

Thank you for this. Save-worthy quote.

 

[FlowRate]

I deleted an earlier version of my post but we're pretty much on that topic. I have a few dysthymia/depressive PD folk on my panel right now and it can get really draining/disheartening (which is sorta the expected CT but that doesn't make it any more pleasant to deal with.)

 

[Marasmus1]

I actually found medicine more emotionally draining than psychiatry.

 

[MBBSMOM]

I actually found medicine more emotionally draining than psychiatry.

Psychiatry is also part of medicine.

 

[Mad Jack]

I'm dead inside, so psych doesn't bother me in the slightest

 

[Evidence Based]

Psychiatry is also part of medicine.

Nobody here would disagree with you, but in this context "medicine" is shorthand for your internal medicine rotations during intern year.

 

[Mad Jack]

Nobody here would disagree with you, but in this context "medicine" is shorthand for your internal medicine rotations during intern year.

Yeah, while psych issues come up in inpatient medicine, they generally seem to get turfed to my consult service, with varying degrees of legitimacy

 

[sloop]

Yeah, while psych issues come up in inpatient medicine, they generally seem to get turfed to my consult service, with varying degrees of legitimacy

I will still roll my eyes about certain consult questions, but I think that the more experience I’ve gotten, the more I’m starting to take the perspective of “well, I’d rather them ask something they’re worried about even if it’s something I can just reassure them about and move on than not ask something that might be important.”

Also, having been on busy inpatient medicine services, sometimes you have to consult just because whatever intervention might be indicated is just outside your typical wheelhouse enough that handling it on your own would require time that you just don’t have. I’ve done some consults on a variety of services (psych, neuro, etc) that I felt the primary team probably should have been able to figure out on their own, but I was happy to do them because I also know that their mental energy is directed to making sure the patient’s 25 other health issues don’t kill them. Happy to spend 20 min with the patient plus 15 minutes of staffing to diagnose Bell’s Palsy if it takes some load off the consulting team. Likewise, I’m okay reassuring people now and again that this is, indeed, delirium and they should continue treating the medical problems and it should get better (but hey here’s a dot phrase of helpful tips to manage behavioral disturbance in delirium without snowing the patient).

Capacity evaluations, however, I do not really appreciate, but usually people are receptive when I explain why it’s their job but offer to share my dot phrase which walks them through evaluating capacity.

 

[FlowRate]

Capacity evaluations, however, I do not really appreciate, but usually people are receptive when I explain why it’s their job but offer to share my dot phrase which walks them through evaluating capacity.

I wish we had that kind of support. So many BS capacity evaluations... Granted, the CL types really enjoy being able to point out that 75% of the time it's not actually about capacity and moreso about spending time with the patient, clarifying disagreements, etc. Also very frequently the patient does have capacity so then it's treating the team's anxiety about letting people make bad decisions.

 

[Armadillos]

Outpatient was the first time I really started feeling the "holy $#!+... no one is getting better... what the F are we doing here" thing.

Makes me wonder if you are seeing patients in what has been a long term resident clinic with patients getting passed down for years? Because outside that weird setting which doesn’t seem to be “real life”, outpatient psychiatry has been a completely different experience for me.

For me starting outpatient was more like “damn Prozac/buspar/invega sustenna/etc actually work”

 

[clausewitz2]

I wish we had that kind of support. So many BS capacity evaluations... Granted, the CL types really enjoy being able to point out that 75% of the time it's not actually about capacity and moreso about spending time with the patient, clarifying disagreements, etc. Also very frequently the patient does have capacity so then it's treating the team's anxiety about letting people make bad decisions.

Ah yes, I will never forget my 4:30 PM Friday consult for capacity evaluation.

"Hi, i'm Dr. Clausewitz with psychiatry, your team asked us to see you. I heard that you wanted to leave the hospital and I wondered if you'd be willing to talk about that."

"Yeah. I'm withdrawing from heroin and these ***holes won't give me any more Norco. I'm in pain and this sucks. I want to go shoot up."

"What's your understanding of what might happen to your [medical condition] if you leave now?"

"Whatever, I'll come back to the hospital if it gets bad, withdrawing is something I can fix."

The hardest part of this consult was making sure the IM team understood that yes, they could document that the patient wanted to leave the hospital to get high and that they would not be in legal jeopardy for this. The patient had told them exactly the same thing and was going to be discharged the next day regardless. I know in some states this might suffice for involuntary commitment but in PA that is absolutely not the case.

One of the interns buttonholed me in the hallway as I was leaving and asked to go over the elements of capacity, which is unheard of in our institution. At least I got to feel like I accomplished something.

 

[clausewitz2]

Makes me wonder if you are seeing patients in what has been a long term resident clinic with patients getting passed down for years? Because outside that weird setting which doesn’t seem to be “real life”, outpatient psychiatry has been a completely different experience for me.

For me starting outpatient was more like “damn Prozac/buspar/invega sustenna/etc actually work”

Oh my God, the first time I had an outpatient come back in saying "wow, I feel so much less anxious with the Buspar, I love it" and I was like "whaaaa? It's not actually a placebo?"

 

[Dharma]

Makes me wonder if you are seeing patients in what has been a long term resident clinic with patients getting passed down for years? Because outside that weird setting which doesn’t seem to be “real life”, outpatient psychiatry has been a completely different experience for me.

For me starting outpatient was more like “damn Prozac/buspar/invega sustenna/etc actually work”

Spot on. I've had a few wins recently... the uninherited cases in particular.

 

[Sushirolls]

Outpatient psych can have a range of recovery. Broad generalizations, medicaid population will make less strides - again this is a broad generalization. Private insurance is more likely to make bigger strides - again this is a broad generalization. You take the wins when they come.

Even if someone might not achieve a large functional improvement, or personal sense of well being improvement, our job is partly to inform them of prognosis and how they can achieve maximal. If the patient chooses not to head your advice, or apply themselves, its on them.

Personally I'm less distraught by the difficult patients or their level of functioning.

Bureaucrats, hospital admin, bureaucracy with charting requirements imposed by admin, etc. These are the things that can get you down. You see the path to improved system delivery, and bam *wall*. Residents, brace yourself for this post residency.

 

[Desired Member]

Oh my God, the first time I had an outpatient come back in saying "wow, I feel so much less anxious with the Buspar, I love it" and I was like "whaaaa? It's not actually a placebo?"

Or was it?