I love psych... But, am I going to miss medicine?

[nontradmomma]

You won't miss medicine. I get to do a LOT of it constantly.

Just THIS WEEK on the wards I have diagnosed Stiff Person Syndrome (150 cases in the last 25 years) most likely neoplastic variant and am currently digging for the cancer, am working on diagnosing an endocrine abnormality making this girl look like a adolescent boy who is psychotic and paranoid she is being poisoned so drinks so much water she got hyponatremic to 126, most likely an adrenal tumor of some kind at this point), am managing severe rheumatoid arthritis, and have a severe anorexic who recently had a hemoglobin of 2.8. And I'm only carrying 5 patients.

Psych patient are among the sickest medical patients you will have. To make matters worse, they get marginalized much of the time by the "Medicine" doctors, who TEND to attribute all of their problems to their psychiatric disorders. Here are some absurd things I have seen:

1. A 65 year old lady with a history of schizophrenia who fell, hit her head, with LOC, then came into the ED with AMS. Guess what? No head CT. Admitted to medicine for electrolyte derangement, then psych consult. Psych consult ordered a Head CT, turns out she had a freaking stroke. What 65 yo head injury, fall, LOC, with AMS doesn't get a head CT?!? The one with a history of schizophrenia. Because THAT'S why she's altered. Of course. Proud to say this was NOT at my hospital. Our ER docs are actually pretty good about psych patients generally.

2. A elderly lady (> 70yo) with no past psychiatric history at all, who has waxing and waning mental status and a dirty urine with a pending culture. Medicine DEMANDS transfer to psych going all the way up to the top of the hospital food chain, because she must have Schizophrenia "because when they gave her Haldol, she got better." Fail.

3. A 64 yo male with a GFR of 12 on dialysis who gets altered on his non-dialysis days. No past psych history. IM again demands psych admit because his altered MS is due to, again, schizophrenia, which he does not have. Refuse to believe that it could be do to his poor renal function. We're taking care of him instead.

Hope that eases your mind. You will still do PLENTY of medicine as a psychiatrist. Even more if you decide to do Psych Consults after residency.

thank you digitlnoize. this got me even more fired up & excited to do psychiatry than i already was. especially the part i bolded. the examples were interesting to the degree i understood them (still premed here, after all). your entire post brings to mind why i'd like to do psychiatry over psychology. my interest is in mental health but my passion is in helping the more vulnerable and marginalized in society. so when a psych patient comes to me one day with physical medical complaints, i want to be able to know how to take it seriously, how to recognize if it is "real" medical issue or something more psychosomatic (or maybe a little bit of both?), i want to be able to truly help on many level, including but way beyond/not limited to just therapy. i want to be able to treat the psychiatric disorders AND be able to recognize, address & maybe even treat other medical conditions, but at least diagnose &/or refer the patient to the appropriate specialist.

i see this with my grandmother with alzheimers, she will have pains and other complaints and i often wonder if & worry that her issues may not be taken seriously due to her advanced age & dementia. she gets this piercing pain in her right eye when she chews & all the doctors say it's just old age (?!) the intensity varies but sometimes she'll go days unable to eat and every time she thinks it's happening for the 1st time since she cant remember that it's been going on (off & on) for years. this can go on for months. then other months will go by where she seems fine & if you ask her she'll swear she's never had an eye problem a day in her life, lol.

but, sorry. that was slightly off topic, but yeah, i can certainly see where some peoples problems could get completely dismissed or misdiagnosed because it MUST be "all in their head". and/or they may not even seek medical attention (&/or poor adherence to treatment) due to their mental illness or dementia or whatever else is going on...

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[smalltownpsych]

thank you digitlnoize. this got me even more fired up & excited to do psychiatry than i already was. especially the part i bolded. the examples were interesting to the degree i understood them (still premed here, after all). your entire post brings to mind why i'd like to do psychiatry over psychology. my interest is in mental health but my passion is in helping the more vulnerable and marginalized in society. so when a psych patient comes to me one day with physical medical complaints, i want to be able to know how to take it seriously, how to recognize if it is "real" medical issue or something more psychosomatic (or maybe a little bit of both?), i want to be able to truly help on many level, including but way beyond/not limited to just therapy. i want to be able to treat the psychiatric disorders AND be able to recognize, address & maybe even treat other medical conditions, but at least diagnose &/or refer the patient to the appropriate specialist.

i see this with my grandmother with alzheimers, she will have pains and other complaints and i often wonder if & worry that her issues may not be taken seriously due to her advanced age & dementia. she gets this piercing pain in her right eye when she chews & all the doctors say it's just old age (?!) the intensity varies but sometimes she'll go days unable to eat and every time she thinks it's happening for the 1st time since she cant remember that it's been going on (off & on) for years. this can go on for months. then other months will go by where she seems fine & if you ask her she'll swear she's never had an eye problem a day in her life, lol.

but, sorry. that was slightly off topic, but yeah, i can certainly see where some peoples problems could get completely dismissed or misdiagnosed because it MUST be "all in their head". and/or they may not even seek medical attention (&/or poor adherence to treatment) due to their mental illness or dementia or whatever else is going on...

I would second this and take it a step further. The intersection between the physical and the psychological is where the sweet spot of the field is. If you emphasize one over the other, you are not going to be as effective. In my current practice, we work together with the medical doc (FM, IM, EM, or Surgery...), Psychiatrist, and Psychologist all working together. We each have a different focus and the psychiatrist is best positioned to be the central figure in the equation. Although, I have seen that it is usually the psychologist who fills this role.