How much improvement do you see?

[Red Beard]

I have been vacillating between medicine and psychiatry over the last few months, with the rank list due for the match in less than one week.

This is why I am bugging the hell out you guys with so many questions, and am thankful for the replies I've received so far.

I've been doing some introspection to determine what my hang-ups are with commitment to one specialty over another. One of the biggest factors for me regarding psychiatry is my need to see relatively frequent evidence that what I am doing is making a real difference, seeing with my own eyes that people are truly getting better/living better/suffering less as a result of the work I do on a daily basis.

I can accept (and be motivated to assist) improvements that take weeks or months.

I can accept not being able to fix things 100% of the time.

If I had to put a number to it, it would be maybe 75%.

Having done only two discontinuous months of psychiatry rotations, I can't say that I've seen much improvement in anyone. I've seen roughly as many people who report being 'much improved' as I have people who are 'back to square one' regarding their illness.

So, again, I ask for input from those of you who have been in the field longer.

For a psychiatrist working with people over the long term, do you feel you see enough real improvement as a result of your treatment that you don't feel like you forever pissing in the wind? Do you think a person with the level of attachment I have to tangible results would end up being too frustrated?

Thanks again, you've all been very helpful.

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[OldPsychDoc]

I have been vacillating between medicine and psychiatry over the last few months, with the rank list due for the match in less than one week.

This is why I am bugging the hell out you guys with so many questions, and am thankful for the replies I've received so far.

I've been doing some introspection to determine what my hang-ups are with commitment to one specialty over another. One of the biggest factors for me regarding psychiatry is my need to see relatively frequent evidence that what I am doing is making a real difference, seeing with my own eyes that people are truly getting better/living better/suffering less as a result of the work I do on a daily basis.

I can accept (and be motivated to assist) improvements that take weeks or months.

I can accept not being able to fix things 100% of the time.

If I had to put a number to it, it would be maybe 75%.

Having done only two discontinuous months of psychiatry rotations, I can't say that I've seen much improvement in anyone. I've seen roughly as many people who report being 'much improved' as I have people who are 'back to square one' regarding their illness.

So, again, I ask for input from those of you who have been in the field longer.

For a psychiatrist working with people over the long term, do you feel you see enough real improvement as a result of your treatment that you don't feel like you forever pissing in the wind? Do you think a person with the level of attachment I have to tangible results would end up being too frustrated?

Thanks again, you've all been very helpful.

I think you may find yourself more frustrated and disillusioned in IM.
Two words: diabetic feet.
How much tangible improvement does that bring to mind?

In psych at least I think you can develop a mind set of "What's the NEXT STEP for this person?" and you can get your jollies from seeing them reach a goal. And every now and then one will knock your socks off and tell you that you're their best doctor ever...and you can ride that triumph for a few days.

 

[Red Beard]

I think you may find yourself more frustrated and disillusioned in IM.
Two words: diabetic feet.
How much tangible improvement does that bring to mind?

Good point.

But in all seriousness, there is something fulfilling to me about taking care of infection, CHF exacerbation, acute renal failure, etc. There is at least a period of increased wellness as a result of what we do before the inevitable readmission and decline.

I would feel the same goodness if I saw enough depression, anxiety, or psychosis unquestionably improve as a clear result of my work, even if they relapse or are never 'cured.'

 

[dl2dp2]

Good point.

But in all seriousness, there is something fulfilling to me about taking care of infection, CHF exacerbation, acute renal failure, etc. There is at least a period of increased wellness as a result of what we do before the inevitable readmission and decline.

I would feel the same goodness if I saw enough depression, anxiety, or psychosis unquestionably improve as a clear result of my work, even if they relapse or are never 'cured.'

This is kind of interesting because I had exactly the opposite experience. In all my IM rotations, we got acute exacerbation of chronic diseases. While a brief course of impatient management stabilized the patient and sent him home, the response per se wasn't dramatic.

The most dramatic improvements that I've seen in my entire medical career, not counting the acute cholecystitis, are ALL psych cases. One was acute psychotic break of a high functioning but refractory paranoid schizophrenic, improved DRAMATICALLY after bilateral ECT. One was first major depression in a bipolar, improved pretty dramatically after lithium. Third one was a OCD/severe anxiety case, basically improved quite dramatically after 3 days of Prozac+benzo.

My impression is in psych the drugs tend to really work their magic quickly, but in the long run there's always some "residuals". Of course, not everyone responds to meds. But I find in hospitalist IM the prospect of essentially end-of-life/DC to SNF kind of management quiet depressing.

IM subspecialties, however, are a totally different beast. I think there IS something special about putting in a stent, or giving that Addison's steroids. If this is what you are looking for, then you should do IM. I think you have to be fundamentally more interested in the CNS than any other organ in order to jump the gun and do psych. Although, on the other hand, if a "cure" is what you are looking for, there are also subspecialties, such as addiction, in psych, where "cures" are feasible.

 

[Shrink Wrap]

Because you are vacillating between medicine and psychiatry (as I am), I would suggest you check out the following thread

http://forums.studentdoctor.net/showthread.php?t=701829

Specifically:

psychotrope
Senior Member


Join Date: Jul 2007
Posts: 137

Quote: Originally Posted by Shrink Wrap
Thanks for the encouragement. I'm starting to feel much better about everything.
I think the reason that I had such a hard time deciding is because I'm very attracted to areas that interface between medicine and psychiatry -

break it down to it's core with a question: It's 7pm on a "short call" and the phone rings with an admit from the ED. Would you prefer it to be:​

1) a multiple admit with end stage liver disease who still drinks a ton and will need tapped just before you leave for the night and just after you admit him
2) a multiple admit with borderline who is having issues with her mom again and took 10 klonopin and will probably require(or get is a better word) admission after you go down and see her​

Which one of those everyday cases would you be more interested in picking up the phone for? For me it's #2.....if it's not for you, do medicine instead. ​

And just to throw in my two cents, if you need to be in a field where you can really see some improvement choose psych. At least then you'll have a chance. If you go into medicine, you would need to select a subspecialty where you can actually cure somebody of something. The rest of it seems to revolve around chronically ill people with multiple major medical comorbidities who are never going to stop smoking/drinking/sleeping around/smoking crack etc. no matter how many times you admit them and adamantly encourage them to change their lifestyles. At least that's my experience where I'm at.

 

[babel]

Just an MS3 here with only a single month of Psych under my belt, and I have to say that the amount of improvement I saw is pretty much the major reason that I fell in love with Psych (in addition to a strong interest in the basics of the mind and behavior, of course). I'm sure it's all a matter of perspective, and like what OPD said, I for whatever reason am just particularly satisfied by what may seem like minor changes to others, but hey, it works for me.

I can think of so many examples from my 4 short weeks - the young college educated woman with a family whose first manic episode quickly evolved to psychosis and whose family cried in joy when they saw her able to talk and interact and sleep a week later; the middle aged woman with refractory MDD whose movement, thoughts, and speech were all slowed down to virtually nothing who literally seemed to come back to life over the course of 7-8 ECT treatments; the young schizophrenic who said the voices telling her to kill herself went from constant and loud to barely audible whispers that she could handle and ignore;...... you get the picture. Will these people relapse? Sure. But I still felt more inspired than I have in any other field of medicine seeing these people obtain even small and/or temporary achievements. Perhaps it is because I see their suffering as so great when they first come to us that I find even the smallest changes to be so amazing. What can I say - psych is just awesome.

 

[babel]

Wow, impressive that 3 of us posted very similar responses within just a 9-min time frame!

 

[Doctor Bagel]

This is kind of interesting because I had exactly the opposite experience. In all my IM rotations, we got acute exacerbation of chronic diseases. While a brief course of impatient management stabilized the patient and sent him home, the response per se wasn't dramatic.

The most dramatic improvements that I've seen in my entire medical career, not counting the acute cholecystitis, are ALL psych cases. One was acute psychotic break of a high functioning but refractory paranoid schizophrenic, improved DRAMATICALLY after bilateral ECT. One was first major depression in a bipolar, improved pretty dramatically after lithium. Third one was a OCD/severe anxiety case, basically improved quite dramatically after 3 days of Prozac+benzo.

My impression is in psych the drugs tend to really work their magic quickly, but in the long run there's always some "residuals". Of course, not everyone responds to meds. But I find in hospitalist IM the prospect of essentially end-of-life/DC to SNF kind of management quiet depressing.

IM subspecialties, however, are a totally different beast. I think there IS something special about putting in a stent, or giving that Addison's steroids. If this is what you are looking for, then you should do IM. I think you have to be fundamentally more interested in the CNS than any other organ in order to jump the gun and do psych. Although, on the other hand, if a "cure" is what you are looking for, there are also subspecialties, such as addiction, in psych, where "cures" are feasible.

I felt entirely the same way as you in my IM and psych rotations. I felt like we did very little to actually improve someone's life on IM. A super sick patient came in with some sort of exacerbation of something. We stabilized it, but they left the hospital still super sick and not very functional. Most of the patients I saw are probably dead now honestly or have been hospitalized 50 million times for the same thing and still living a pretty miserable existence. In the clinic, I saw patients with chronic conditions like htn and dm that were helped a little by medication management and advice on lifestyle modification, but it seemed like most of the patients remained hypertensive, diabetic or obese.

With psych, though, at the time of discharge, a patient would seem like a totally different person from who they were at admission. Sure, they might get back to whatever low point they were at before hospitalization/treatment, but lots had moments of really significant recovery. I can't say that about the 85 y/o CHF, lung ca patients I saw on IM.

 

[The Long Way]

Similar to experiences had by others who have posted, it has been my experience that some of the most obvious improvements in my patients' quality of life have been on my psych rotations.

I think that some of this is that goals are more realistic in psych. We tend to recognize that sometimes the goal is to simply control symptoms and get the patient stable, and by doing so, we have drastically improved the patients quality of life. Even though we often fail to "cure" the patient, I have found a much greater proportion of my patient encounters to be satisfying in psychiatry that in any of my other rotations.

While there certainly is something to be said for medical subspecialties, primary care IM has always been dissatisfying to me. Most of my time on these rotations has been spent managing acute exacerbations of poorly controlled chronic conditions in noncompliant patients. One of my IM attendings (who advised me to avoid IM) compared IM to "rearranging chairs on the Titanic..."

 

[Doc Samson]

CL Psychiatry is great for those of us afflicted wtih a relatively short attention span. We get the medically complex cases, often with some neuropsychiatric presentation, and we get to look really smart when we diagnose them with delirium, NMS, serotonin syndrome, catatonia, Hashimoto's encephalopathy, paraneoplastic limbic encephalitis, or whatever we find, recommend a course of treatment, and watch the pt get better farily quickly. All that, and we don't have to write our own orders, take overnight call, and are generally beloved by nursing staff.

 

[Red Beard]

CL Psychiatry is great for those of us afflicted wtih a relatively short attention span. We get the medically complex cases, often with some neuropsychiatric presentation, and we get to look really smart when we diagnose them with delirium, NMS, serotonin syndrome, catatonia, Hashimoto's encephalopathy, paraneoplastic limbic encephalopathy, or whatever we find, recommend a course of treatment, and watch the pt get better farily quickly. All that, and we don't have to write our own orders, take overnight call, and are generally beloved by nursing staff.

Not to de-rail my own thread, but have you actually diagnosed either of these?

If so: far out!

 

[Doc Samson]

Not to de-rail my own thread, but have you actually diagnosed either of these?

If so: far out!

Hashimoto's once and PLE a few times.

 

[peppy]

While IM does tend to have the reputation that much of what they do is "playing keep away with the grim reaper", you should go into psych being aware that you will see a lot of frequent fliers there too. There are a considerable number of psych patients who will have many cycles of "admitted in crisis, stablized in the hospital, sent home doing well, then decompensate for one reason or another and head back to the hospital". In many areas there are not enough resources to keep these patients on their meds as outpatients (let alone room for long-term institutionalization) so you'll see them again and again.

I do think that it helps if you think you can be satisfied with small victories. Personally, I tend to think of Surgery or Emergency Med as being fields that are more likely to offer a lot of dramatic improvements and quick turnarounds.

 

[Psych2014]

This is an interesting thread. I think the question lies in weather psychopathology and psychiatric care or physical pathology and it's care gets naturally sparks your interest, causes a desire to learn, and help. That seems like the daily issue you'll encounter in whichever specialty you choose, because in both, people doen't seem to stay well, especially as they age.

Good luck in your choice.

 

[peppy]

This is an interesting thread. I think the question lies in weather psychopathology and psychiatric care or physical pathology and it's care gets naturally sparks your interest, causes a desire to learn, and help. That seems like the daily issue you'll encounter in whichever specialty you choose, because in both, people doen't seem to stay well, especially as they age.
Good luck in your choice.

I think that's a good way to put it. Every field has to deal with certain grinding aspects. One reason I think psych is for me is because I prefer getting paged by nurses when I'm on call about agitation/anxiety rather than things like chest pain and shortness of breath.

 

[DrFrasierCrane]

I have to agree with most of what everyone has said and I, too, felt that I saw some of the most profound changes in my patients during my psych rotation. I think a large part of that has to do with why I like psych to begin with. Psychiatry is really about treating the person and you SEE your results. You know when your patient is better because they are no longer talking to the wall but having a conversation with you.

In IM, other than treating infections, the changes you "see" are so often just numbers: "Halleluja! His Cr is down to 0.9! He's saved!" "Looks like the PEEP is up to 12 today with an FiO2 of 80, things aren't looking good." etc. That to me just wasn't very satisfying. But telling a mother on the phone, "we've stabilized your son, he's able to sleep now and he no longer is threatening to kill himself" was quite gratifying.

Again, as others have mentioned, the IM subspecialties are better. And it is true that there is lot of frequent fliers and malingerers, but there's still nothing out there quite like some of the powerful and inspirational changes I saw in psych.

 

[nancysinatra]

While IM does tend to have the reputation that much of what they do is "playing keep away with the grim reaper", you should go into psych being aware that you will see a lot of frequent fliers there too.

This is extremely true. As a psych intern who did 6 months of call from July to Dec there were patients I admitted no less than 5 times, whom other interns I shared call with never even saw. What that means is that there are patients who literally come in on a q5 basis, corresponding to my exact call schedule. (When I wasn't admitting them, they were in the hospital). Other interns admitted other frequent fliers on a similar basis. There are other patients who come in daily, mind you! Don't fool yourselves that you'll "cure" these patients. They will plague you as residents! There are many reasons to go into psychiatry but curing all or even a majority of the patients is not one of them. Not a single "cure" exists in psychiatry that I'm aware of. We have many medications, most of which have serious side effects and our patient don't take, as a result. I think you really have to go into psychiatry having an awareness of the long term struggles patients will face, on many fronts.

Take a look at the prognosis of psychiatric illnesses, and THEN compare to IM. A lot of IM is GI bleeds, the flu, or if it's chronic, it can be managed if the patient is compliant. And some of those diseases can be shipped off to surgery, which never happens in psych. I would honestly say in psych, unless you are dealing with something super discreet like arachnophobia (never) you are unlikely to achieve much "curability" at all. (Caveat: I don't know how curable arachnophobia is but I hope one day to have a patient with this and only this as their CC just to find out!)

Just for example, an anorexia nervosa patient has on average something like 7 inpatient admissions before they even start to get better. Alcoholics relapse I don't even know how many times. Bipolar disorder is one of the world's most disabling illnesses. Schizophrenia... medications help but we are far from a cure. Antisocial personality disorder--I'm not quoting EBM here, but I think I've actually read somewhere where it was advised for experienced psychotherapists not to even try to treat it! And compliance is always an issue in psychiatry.

I'm not trying to discourage people but just say, look at the natural history of psychiatric illnesses before waxing poetic about the "influence" you'll have. You should have a true interest in the material itself.

 

[Red Beard]

This is extremely true. As a psych intern who did 6 months of call from July to Dec there were patients I admitted no less than 5 times, whom other interns I shared call with never even saw. What that means is that there are patients who literally come in on a q5 basis, corresponding to my exact call schedule. (When I wasn't admitting them, they were in the hospital). Other interns admitted other frequent fliers on a similar basis. There are other patients who come in daily, mind you! Don't fool yourselves that you'll "cure" these patients. They will plague you as residents! There are many reasons to go into psychiatry but curing all or even a majority of the patients is not one of them. Not a single "cure" exists in psychiatry that I'm aware of. We have many medications, most of which have serious side effects and our patient don't take, as a result. I think you really have to go into psychiatry having an awareness of the long term struggles patients will face, on many fronts.

Take a look at the prognosis of psychiatric illnesses, and THEN compare to IM. A lot of IM is GI bleeds, the flu, or if it's chronic, it can be managed if the patient is compliant. And some of those diseases can be shipped off to surgery, which never happens in psych. I would honestly say in psych, unless you are dealing with something super discreet like arachnophobia (never) you are unlikely to achieve much "curability" at all. (Caveat: I don't know how curable arachnophobia is but I hope one day to have a patient with this and only this as their CC just to find out!)

Just for example, an anorexia nervosa patient has on average something like 7 inpatient admissions before they even start to get better. Alcoholics relapse I don't even know how many times. Bipolar disorder is one of the world's most disabling illnesses. Schizophrenia... medications help but we are far from a cure. Antisocial personality disorder--I'm not quoting EBM here, but I think I've actually read somewhere where it was advised for experienced psychotherapists not to even try to treat it! And compliance is always an issue in psychiatry.

I'm not trying to discourage people but just say, look at the natural history of psychiatric illnesses before waxing poetic about the "influence" you'll have. You should have a true interest in the material itself.

Interesting perspective, thanks for sharing.