Intern Year

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SMC123

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10+ Year Member
I am current third year student interested in psychiatry. I had some questions regarding intern year. I am very anti IM, FM, EM, Peds. It just doesnt make sense to me. I suck at making a differential diagnosis from my history, donducting a PE that helps me, or knowing what to write for assessment/plan. I also never know what labs or tests to order, and want to stay away from all this ordeal as much as possible.

I was curious to know are there psych residencies that have very limited to none medicine involved intern year? If not, are there certain residencies that are mostly outpatient? I feel like outpatient FM or IM I could deal with better. I just get so lost seeing residents putting in orders and really don't want to go through it.
 
Please tell me this is an April Fool's thing. I try to be pretty encouraging of everyone, but if that's your attitude you are going to be a bad doctor, no matter what specialty you go into. I suggest you either figure out how to be passable at those things or find a non-clinical specialty to go into. Psychiatric patients have medical problems just like everyone else. They actually have more medical problems than anyone else, many of which you need to either be able to rule out or understand in order to treat them effectively. And because of all sorts of issues, their medical problems either go undiagnosed, untreated, or undertreated a lot of the time. Sometimes we are the only doctor there for them, sometimes we're just the only ones who take the time to listen and figure out what's going on.

Regardless, you can't be a good psychiatrist without at least a little competence in general medical issues.
 
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SMC123 said:
I am current third year student interested in psychiatry. I had some questions regarding intern year. I am very anti IM, FM, EM, Peds. It just doesnt make sense to me. I suck at making a differential diagnosis from my history, donducting a PE that helps me, or knowing what to write for assessment/plan. I also never know what labs or tests to order, and want to stay away from all this ordeal as much as possible.

I was curious to know are there psych residencies that have very limited to none medicine involved intern year? If not, are there certain residencies that are mostly outpatient? I feel like outpatient FM or IM I could deal with better. I just get so lost seeing residents putting in orders and really don't want to go through it.
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Are you on a traditional schedule? If not, how far along are you in third year? It's not uncommon to feel lost during the start of third year. If you're a U.S. student near the end of third year, this might be an issue. If you're an IMG or FMG who just started third year, it'll get better. You'll learn more as the year goes on and you'll get better at differentials and A/P. You just have to study, ask questions, and ask for help when you need it.
 
SMC123 said:
I am current third year student interested in psychiatry. I had some questions regarding intern year. I am very anti IM, FM, EM, Peds. It just doesnt make sense to me. I suck at making a differential diagnosis from my history, donducting a PE that helps me, or knowing what to write for assessment/plan. I also never know what labs or tests to order, and want to stay away from all this ordeal as much as possible.

I was curious to know are there psych residencies that have very limited to none medicine involved intern year? If not, are there certain residencies that are mostly outpatient? I feel like outpatient FM or IM I could deal with better. I just get so lost seeing residents putting in orders and really don't want to go through it.
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Here's what the ACGME requires of us:
"a minimum of four-months in a primary care clinical setting that provides comprehensive and continuous patient care in specialties such as internal medicine, family medicine, and/or pediatrics. "
I am not personally aware of a program that does all 4 months as outpatient, but it does not appear to be a priori excluded as an option.

The other thing it occurs to me to add is that these months are necessary in most states to support licensing requirements, USMLE Step 3, etc.
 
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SMC123 said:
I suck at making a differential diagnosis from my history, donducting a PE that helps me, or knowing what to write for assessment/plan. I also never know what labs or tests to order, and want to stay away from all this ordeal as much as possible.
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So what makes you think you'd be any good at psych?
 
I actually know the diseases. there arent a lot of things you can do for plan besides therapy or psychpharm. also you dont have to go around checking heart and lungs, I believe. For instance you dont realy order a cbc or ct scan in psych.
 
SMC123 said:
I actually know the diseases. there arent a lot of things you can do for plan besides therapy or psychpharm. also you dont have to go around checking heart and lungs, I believe. For instance you dont realy order a cbc or ct scan in psych.
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Have you done your psych rotation yet???
It doesn't really sound much like you have...
 
SMC123 said:
I am very anti IM, FM, EM, Peds. It just doesnt make sense to me. I suck at making a differential diagnosis from my history, donducting a PE that helps me, or knowing what to write for assessment/plan. I also never know what labs or tests to order, and want to stay away from all this ordeal as much as possible.
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If you don't like the unknown, vague symptoms, and coming up with differentials, you would REALLY hate psychiatry.

Have you considered pathology? There are a lot of set procedures they follow to fulfill requests other physicians ask of them. It might be more to your liking.


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the thing with psych is I can act come up with a differential since I know the diseases.with medicine I dont even know what the treatment for pe is, or what test to conduct right away
 
SMC123 said:
I actually know the diseases. there arent a lot of things you can do for plan besides therapy or psychpharm. also you dont have to go around checking heart and lungs, I believe. For instance you dont realy order a cbc or ct scan in psych.
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Hate to break it to you, but many psych drugs have physical side effects that you need to recognize immediately and know what to do about it and that includes which tests to order if need be. No, it's not like IM, but if you're practicing psychiatry well, you're going to be keeping tabs on your patient's medical conditions. If someone has a heart condition, you need to know about it. If someone has kidney disease, you need to know about it. If someone has liver disease, you need to know about it. All of that is going to affect your choice of medications. Also, don't forget that a part of psych residency will be at least a few months in a consult role, which means you will be consulted by other services to determine if there is anything that can be done for a patient psychiatrically. These will be patients who have a number of medical issues. You can't just show up and start putting in orders willy nilly. You have to do an actual assessment and a big part of that will be to determine if the problem you were consulted about is actually psychiatric. You can't do that unless you know your medicine.

Just read your latest. Have you taken Step 2 yet? If not, you will know what test to order for a PE and what to do about it or else you won't pass. Step 2 is all about the next step. If you don't know what to order for a suspected PE, you need to start studying ASAP.
 
SMC123 said:
the thing with psych is I can act come up with a differential since I know the diseases.with medicine I dont even know what the treatment for pe is, or what test to conduct right away
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General medical disorders are always on the differential for psychiatry (especially delirium, neurological illnesses that look psychiatric, endocrine disorders like hypothyroidism or steroid-induced mania, a wide range of toxidromes, etc) so you should look outside of just psychiatric diagnoses when approaching a patient. Regardless, most of us are not pros at evaluating and managing patients by the end of third year of medical school. You pick it up with practice. Keep at it and you will probably be fine (especially if your grades and test scores are good). As has already been said, you are in for four months of medicine and two months of neuro in psych residency but some programs will let you do part of that outpatient or give you a reduced patient load. If you are still very intimidated by medicine as you are applying take a look at their rotation lineup and ask about these things on interview day.
 
Thank you for the encouraging words. I'm sorry if I offended someone. I understand psych is not just knowing drugs and talk therapy. However, what I was getting at is, as a psychiatrist, your main focus is on prescribing psych drugs and knowing their side effects. As in IM, you are responsible for ALL drugs. I don't think psychiatrists go around prescribing gout or blood pressure medications. Also, I understand that I will be dealing with patients that will have numerous med conditions. However, the IM service will be doing the workup on all these possibilities. My job will be to go in and do the consult regarding psych. I understand CBC and other tests may help lead me into a psych diagnosis, whether it be endocrine related or not, but the differential based on the CBC will be a lot more specific and limited than if i was in FM or IM. I hope this makes sense. Please tell me if I'm wrong. A lot of people going into psych because they dont like touching patients, or conducting a thorough physical examination. I believe this is pry the case during residency too. An extreme workup is not needed as it would be in medicine.
 
Hey SMC123, April Fools ended yesterday my friend. You can stop the joke. You are insulting not only psychiatry, but also yourself if you're for real.... which is why I think this is a joke thread.
 
Leo Aquarius said:
Hey SMC123, April Fools ended yesterday my friend. You can stop the joke. You are insulting not only psychiatry, but also yourself if you're for real.... which is why I think this is a joke thread.
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Unfortunately, I believe they're serious--having already described themselves elsewhere as "a struggling do student looking for a chance at one of the struggling programs" and having failed COMLEX 1 at least once.
 
You didn't offend me. You scare the piss out of me.

You've now had several senior residents and attendings offer you something between gentle and harsh rebukes in this thread and you still don't seem to be getting it. Your job isn't going to be to treat 'psych issues', your job is going to be to treat people. All kinds of people, all of whom have one psych issue or another. Most of whom also have medical issues. Some of them will have PCPs, some won't. Many of those that have PCPs won't see them very often, will fail to communicate their somatic issues due to their mental disease, or may not even recognize that they have them going on.

Your patients deserve better than for you to just pass over their medical issues. And if you do persist in that mindset, I guarantee that your patients will become sick, disabled, and some will even die because you overlooked something you COULD have intervened in. Sometimes you'll simply communicate your concerns to the PCP, sometimes you'll send them to the ED, and sometimes (god forbid) you will actually have to get your hands dirty and order tests or even treatment for general medical issues. Several studies have been done on medical comorbidity in psychiatric patients. Just shy of 50% will have some sort of active medical issue. Just under half of those will have an issue that has gone undiagnosed. So what you are saying is that for a quarter of your patients, you're ok just assuming someone else is taking care of it. And for another quarter of your patients, you don't see it as a big deal if you fail to diagnose their chronic health issues.

There's a reason we all get the same major rotations. It's so we at least have a level of familiarity and basic competence with all aspects of medicine. No one expects you to be an internist, but they do expect you to know enough of the basics to know when something's wrong.

Patients deserve better.
 
It is correct that you typically will not have to do the extensive medical workup that an internist might do on a complicated or unstable patient. However, as others have stated, you need to be able to recognize when an illness is medical rather than psychiatric, and this is not always simple (e.g. anti-NMDA receptor encephalitis, paraneoplastic syndromes, etc.). You will need to know AT LEAST enough about these syndromes to recognize them as a possibility that should be on your differential, figure out how urgent the situation is, and find the appropriate service to investigate further.

In addition, you WILL need to know basic primary care and basic emergency medicine when you are managing inpatients. At most residencies, a large portion of your time will be on inpatient units or night float. You need to know what to do when you get called for a patient with acute chest pain at 2 am. At my residency, it is expected that you know how to do things like examine the patient, get an EKG and interpret it, and order and interpret cardiac enzymes. You shouldn't send every patient to the ED, so you need to be able to triage these situations and start a basic workup. In addition, you will be expected to be able to, say, follow JNC guidelines and start a stable patient on an appropriate initial medication for their hypertension. Yes, for complicated situations, you will be able to get assistance from consultants, but it will generally be expected that you have put forth some effort to manage the situation yourself first. Also, as a psychiatrist, you routinely order and intrepret the results of basic labs (CBC, Chem panel, liver panel, TSH, UA) and you frequently order head CTs as well.
 
I think it may be harder for a lot of MDs to get where SMC123 is coming from, but as a DO, it is very understandable to me. A lot of us go through 3rd and 4th year without ever writing notes, talking to patients, coming up with differentials, workups, or treatment plans. Some of us spend our core rotations shadowing nurses and medical assistants or quietly observing a physician from the corner. It's only natural to feel completely incompetent. The thought of being thrown into residency where we are actually responsible for doing these things is terrifying to many of us, present company included.
 
Euthymia said:
I think it may be harder for a lot of MDs to get where SMC123 is coming from, but as a DO, it is very understandable to me. A lot of us go through 3rd and 4th year without ever writing notes, talking to patients, coming up with differentials, workups, or treatment plans. Some of us spend our core rotations shadowing nurses and medical assistants or quietly observing a physician from the corner. It's only natural to feel completely incompetent. The thought of being thrown into residency where we are actually responsible for doing these things is terrifying to many of us, present company included.
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If that is widely the case, this does not speak well for DO training, nor bode well for DO students hoping to compete for MD residencies.
 
Maybe pathology would be a more viable choice? I have a friend who really despises any patient contact so he's doing a pathology residency. And as far as I know, pathology is the only specialty where you essentially have no patient contact at the bedside. As others have said, psychiatry is mandated to have medicine experience.

I think for psychiatry it will only get better in terms of clearly separating the current 'muddy' mood/psychosis/anxiety/etc. disorders into distinct clinical entities that are differentiated by their pathophysiology/treatment/course (which other medical fields already clearly have....ie STEMI vs NSTEMI vs UA). And as such you will definitely need to be able to generate a differential on initial encounter then narrow down a diagnosis to drive the treatment for that disease. As a PGY-1, I'm optimistic that that will be the future for our field of psychiatry within my career lifetime and it should certainly be very exciting. Maybe DSM 7/8?
 
OldPsychDoc said:
If that is widely the case, this does not speak well for DO training, nor bode well for DO students hoping to compete for MD residencies.
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I am a DO student, and this was not my experience whatsoever. I wrote plenty of H&Ps and progress notes using EMR and was asked to come up with differentials. I have had several hundred patient encounters on my own.

There can be very occasional rotations like that where you are just shadowing and not doing much, but for the most part I was satisfied with the push I was getting. In 4th year, I set up several rotations using VSAS and worked alongside MD students. My classmates did the same. Sure, there are things I wish I did differently during med school. I wish I read more, and did more question back boards questions. But I felt that my rotations were appropriate, as I had researched my options before ranking my rotation preferences. As DO students with large class sizes, high quality rotations weren't always given to us (especially ward based rotations), but many of us had to make the effort to seek them out through our school and get others on VSAS.

Having worked alongside MD students in my area, I will admit that at times their formal didactics were better. They got a LOT more didactics offered in 3rd and 4th year than we did. I was jealous of the incredible support their school offered that I never had. However, conversely, those of us DO students who worked directly with attendings got chances to do more procedures than some MD students who had to stand back while residents took procedures. So it really depends. From my limited observations, the MD school in my state seemed to offer more consistency of training and more student support. However, that being said, many of my classmates are truly brilliant people and have put in the effort to get to where they have gotten. They got excellent training as they made it happen, and I have no doubt these people will be excellent physicians. For the most part, I haven't seen much difference between DO and MD students and residents that I've rotated with, and you can't tell them apart at all.

My experience is limited to my program. There are other DO schools who have their own affiliated hospital, and thus they can get consistent quality of rotations as well.
 
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Euthymia said:
I think it may be harder for a lot of MDs to get where SMC123 is coming from, but as a DO, it is very understandable to me. A lot of us go through 3rd and 4th year without ever writing notes, talking to patients, coming up with differentials, workups, or treatment plans. Some of us spend our core rotations shadowing nurses and medical assistants or quietly observing a physician from the corner. It's only natural to feel completely incompetent. The thought of being thrown into residency where we are actually responsible for doing these things is terrifying to many of us, present company included.
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Aaaaaaaaaaand the uphill battle many DOs face in securing choice residency spots just got vertical...
 
I keep seeing Pathology offers being listed instead of doing Psych. I don't know if any of you have heard, it is VERY hard to find a job once done with a Path residency. One can clearly make this call after viewing their forum. Why waste so much time (4 years) in training to not being able to practice? I'll take my chances with Psych.
 
SMC123 said:
I keep seeing Pathology offers being listed instead of doing Psych. I don't know if any of you have heard, it is VERY hard to find a job once done with a Path residency. One can clearly make this call after viewing their forum. Why waste so much time (4 years) in training to not being able to practice? I'll take my chances with Psych.
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To say nothing of the fact that if you struggle with differentials, path is definitely not for you.
 
I think the OP is going into psych for the wrong reasons. That being said, he's not really unique. One of juniors transferred from FM and when asked why he basically gave the same answer "because I don't need to know as much". To this day I refuse to talk to him nor will I refer patients to him.

SMC, you will not be a good doctor no matter what your speciality with that kind of attitude. Being good at something requires passion and curiosity. And you lack them both.
 
I attended a famous top 20 medical school and got the crap beat out of me in terms of training until I turned blue ~ I wrote tons of notes, made tons of differentials, rounded with amazing teachers who loved medicine, did tons of physical exams with extra training in high tech simulation labs. It was rough going through it. But I'm sure glad I did because medicine is second nature to me like the back of my hand, and I couldn't imagine becoming a doctor not having this grueling training. And this brings me to my point. Whether you're a DO or MD, if you haven't had amazingly DIFFICULT and EXTENSIVE medical training then you should NOT become a physician. Am I being harsh? Yep.
 
Just another DO student here... and I have to say that it would be very unfortunate if someone read this thread and thought that this person's point of view was representative of all of us, or that most/all of us have poor training. Like rkaz I can only speak for myself and my school, but I've been fortunate to have some excellent clinical training through my DO program, and worked alongside MD students frequently performing the same tasks and holding the same responsibilities. I'm on an ER rotation right now at the end of my fourth year, and I've been able to see patients independently, do procedures, and come up with assessments/differentials/plans. I'm not saying I'm a rockstar or anything (far from it), but I do at least feel like I'm competent, and have the skills necessary to find the right help when I need it in a clinical scenario.

Sorry - I know that's not what this thread is about, but it struck a nerve.

As to the original topic here, I think there are a lot of people in psych who didn't fall in love with the super physical medicine parts of medicine. Working the wards certainly wasn't my favorite experience in the world, but like so many people pointed out above, it was an important part of my education (and will continue to be educational in intern year, I'm sure). If I have a patient with diabetes or heart failure, I want to know about the lifestyle choices that could help them live better lives, and recognize the signs that their physical problems need more of a workup. I want to be able to recognize delirium, seizure disorders, liver disease, and heart attacks - just like any other competent physician. One thing I've learned from doing psych electives in 4th year is that medicine-medicine is still incredibly important, and psychiatry is way more complicated than "just psychopharm and psychotherapy" if you're doing it right. That's part of what makes this field so interesting.

Please don't be a lazy psychiatrist or a lazy DO. Neither of those groups need any more negative press, and patients deserve better. Hopefully as you moves forward in school and gain more experience you'll get more comfortable with medical scenarios, and maybe even find them interesting in some way.
 
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Daedra22 said:
Just another DO student here... and I have to say that it would be very unfortunate if someone read this thread and thought that this person's point of view was representative of all of us, or that most/all of us have poor training.
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I'm sure some DO schools have lots of awesome sites where all the students get great clinical training. But the opposite of this certainly doesn't seem uncommon. I base this on the experiences of many people at my school and the few hundred posts in the "Rotations suck..not learning anything" thread in the osteopathic forum.

Sorry, don't mean to derail the thread. I'll hush up now so everyone can get back to rebuking SMC123.
 
Euthymia said:
I'm sure some DO schools have lots of awesome sites where all the students get great clinical training. But the opposite of this certainly doesn't seem uncommon. I base this on the experiences of many people at my school and the few hundred posts in the "Rotations suck..not learning anything" thread in the osteopathic forum.

Sorry, don't mean to derail the thread. I'll hush up now so everyone can get back to rebuking SMC123.
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Please anonymously report your school to the AOA (not that it'll do much). Another DO student here just reporting in that has had to write notes and see pts on my own in EVERY rotation, and do procedures in many. I think the real difference between between DO and MD as already mentioned is is the structured didactics and school support. THe OP's attitude is his own personal flaw not one of the DO education system.

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SMC123 said:
I keep seeing Pathology offers being listed instead of doing Psych. I don't know if any of you have heard, it is VERY hard to find a job once done with a Path residency. One can clearly make this call after viewing their forum. Why waste so much time (4 years) in training to not being able to practice? I'll take my chances with Psych.
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It'll be harder for you to kill the dead. I'm guessing this is why most are suggesting this.

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it all makes sense now. you guys have been used to everyone using the stigma that psych isnt real medicine and are very against it when someone says it.
 
SMC123 said:
it all makes sense now. you guys have been used to everyone using the stigma that psych isnt real medicine and are very against it when someone says it.
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It's true that we do have some defensiveness about that. It's also true that people who do psych just because they don't like anything else aren't generally happy in psychiatry and don't make good residents or psychiatrists in the long run. Psychiatry is a miserable place to be if you don't actually like something about it.

It sounds like you're having a hard time in your rotations. Third year is hard. I'd suggest focusing on doing what you can to get more out of your experiences (and to feel more comfortable as an MS3 in rotations) and then think about what specialty you might want to do. Hopefully you'll get to a place where you can make a choice where you're going toward something you like rather than running away from things you don't like.
 
I have a lot easier time talking to psych pts and getting their history. In fact, most of the time I am very engaged in what they are saying and questions stem to me naturally. All the diff diseases and diagnosis we have learned about thus far and were on our shelf are very vivid for me, and I can relate a lot. even the psych drugs given out I have a lot of interest in their side effects and efficiency. I guess in a way I am running from medicine and diagnosing kidney failure etc, but going into something I can look forward to and getting out of bed for, whether it be inpatient or outpatient. I also feel like overtime seeing the same pts over and over will help me feel comfortable with them too. I guess with med I am a more introvert person who isnt too hands on or comfortable just meeting someone one time.
 
SMC123 said:
it all makes sense now. you guys have been used to everyone using the stigma that psych isnt real medicine and are very against it when someone says it.
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I don't think these residents and doctors like it when us students continue to cling to misconceptions about the specialty. It's rude and disrespectful to them.
 
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Euthymia said:
I think it may be harder for a lot of MDs to get where SMC123 is coming from, but as a DO, it is very understandable to me. A lot of us go through 3rd and 4th year without ever writing notes, talking to patients, coming up with differentials, workups, or treatment plans. Some of us spend our core rotations shadowing nurses and medical assistants or quietly observing a physician from the corner. It's only natural to feel completely incompetent. The thought of being thrown into residency where we are actually responsible for doing these things is terrifying to many of us, present company included.
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I'm sorry, but please don't ever epeat the above with "a lot of us" again. I'm a DO student and I know of NO ONE who did what you describe. Shadow nurses? Medical assistants? Observe from the corner? Not a soul. If your school is so incompetent that the above is true, I would demand a tuition refund for lack of education. Where did you go to school???
 
MLT2MT2DO said:
Please anonymously report your school to the AOA (not that it'll do much). Another DO student here just reporting in that has had to write notes and see pts on my own in EVERY rotation, and do procedures in many. I think the real difference between between DO and MD as already mentioned is is the structured didactics and school support. THe OP's attitude is his own personal flaw not one of the DO education system.

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Completely agree. It would be really sad if people thought all DO schools/students have this experience. I saw patients by myself on day one of my very first third year rotation. I was writing notes, H&Ps, differentials, and plans. And yeah, I sucked at plans in the first part of 3rd year, but I got much better at them by the end of the year. 4th year has been great and while there are times when I still feel clueless when a patient has a strange presentation or we see a rare disease, I feel I'm competent and on par with my MD colleagues based on the rotations I've done.
 
SMC123 said:
it all makes sense now. you guys have been used to everyone using the stigma that psych isnt real medicine and are very against it when someone says it.
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We're (mostly) a group of people passionate about psychiatry who (at least in my case) are tired of dealing with physicians who went into the field because they could not hack anything else. No patient deserves a bad doctor regardless of the field.

SMC123 said:
I have a lot easier time talking to psych pts and getting their history. In fact, most of the time I am very engaged in what they are saying and questions stem to me naturally. All the diff diseases and diagnosis we have learned about thus far and were on our shelf are very vivid for me, and I can relate a lot. even the psych drugs given out I have a lot of interest in their side effects and efficiency. I guess in a way I am running from medicine and diagnosing kidney failure etc, but going into something I can look forward to and getting out of bed for, whether it be inpatient or outpatient. I also feel like overtime seeing the same pts over and over will help me feel comfortable with them too. I guess with med I am a more introvert person who isnt too hands on or comfortable just meeting someone one time.
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This is a much better reason to go into psych. If you had stated this from the beginning the responses here would be much different. Picking a residency field is as much about ruling things in as ruling things out. Going into any field based solely on the rule outs (I hate endless rounding, I hate procedures, etc.) is a recipe for unhappiness at the least. Best of luck in the process and seek out help if you need it. It's tough to decide what to do with yourself for the rest of your life at any age.
 
Looking back at the original question (and assuming a genuine interest in psych), there are residency programs that do most (if not all) of their required off-service rotations on an outpatient basis. So it's certainly possible to find a residency to fit that bill. But you'll have to come up with a reasonable answer to "Why psych?" to give your interviewers when the time comes to likely get ranked there. Again, best of luck in choosing your future career.
 
To answer the OP's actual question, my interview experience at U.Florida suggested that their IM rotation is pretty chill.

Of course, I agree with the consensus that you need good IM training to be a good psychiatrist. And this is coming from a guy who really doesn't like IM. To the OP - this might seem scary if you feel like your IM training in med school was inadequate. But don't let this intimidation get in the way of your ability to be a good doctor. Aside from the exotic stuff like NMDA receptor encephalitis, you need to be able to figure out when your patient's low mood is caused by uncontrolled hyperglycemia, or when their sleep disturbance is caused by sleep apnea, or when their poor energy is caused by congestive heart failure. On your IM rotations, you'll get good at recognizing how these medical illnesses will mimic psychiatric symptoms. And if you have a patient with the metabolic syndrome, you won't waste their time with purely psychiatric management when it's actually their CHF+OSA+DM that are making them feel crappy.

Anyway - I think that you're asking the wrong question in the original post. What you should be asking is "I'm uncomfortable with internal medicine - how can I fix that?" Remember, residency is primarily about training, not about doing what you're already good at. I don't like managing eating disorders, but that's why I think it's essential for me to do a rotation in eating disorders - I need to learn how to do it. I don't like managing CHF, but it wouldn't be fair to my patients if I didn't have an intimate understanding of how their CHF is being managed. If you're not comfortable with IM, then you need to find a place that offers MORE medicine training, not less. In the long run, the 4 months of pain will likely make you feel better about your ability to help your patients.
 
Exactly what shan said. Also, changing what programs you look at over 4 months out of a 4 year residency makes very little sense.
 
This is a wonderful thread! So full of denial and resentment, of the best sort. Reminds me what drew me to psychiatry in the first place - humans beings in all their irrationality. Now I would like to dispel a few myths.

1) Psychiatrists know their medicine.
- Ok attendings on this forum, without looking it up, what IS the workup and treatment for a PE?

2) The more prestigious the med school, the more clinical experience the students get
- I went to a top 10 med school and we were kicked out of numerous clerkship sites by the burnt out residents in the school's malignant (and frequently on probation) residency programs. The students loved this because it meant more time to study for shelves and Steps which formed the sole basis for our evaluations and hence, our match positions. Progress note - I didn't even know what it was until I got to residency! I emailed the director of the internal medicine rotation a few years back to complain about this unsavory aspect of my overpriced education, and he confirmed, "School X has a policy of not keeping track of student attendance on the internal medicine clerkship. We believe in the honor system." Honor system my arse. There is no honor in medical education. Getting ahead is what counts. At least you are shadowing nurses. We were shadowing no one on some of our clerkships.

3) "You should go into pathology if you are incompetent at differentials."
- Please do not. Pathology is a revered and hallowed specialty and I would much rather see the world filled with incompetent psychiatrists than with incompetent pathologists. Anyone who challenges this is, if you ask me, living in a dream world of denial. I don't know about you guys but when it's my mom who is being evaluated for breast or colon or ovarian cancer, and when chemotherapy choices not to mention surgical decisions are on the line, I really want that diagnosis to be right. Whereas we all know the error rate for diagnoses in psychiatry is off the charts. And the treatment is basically the same (i.e. one of our approximately 50 similar medications) regardless of diagnosis. The way I figure, this guy will do the least damage to patients if he joins us in psychiatry. I am not trying to put down our field, which has its own challenges not described here, I am just being honest. Being diagnostically accurate is not the hallmark of our specialty. That is the hallmark of radiology and pathology.
- Quite honestly it is likely you will fail Step 2, and the point will be moot.

4) It is important to recognize medical causes of psychiatric illnesses, and recognize when a patient has a medical or neurological problem.
- For academic purposes, sure, but in real life, false. Even when a unicorn of a diagnosis comes along, like NMDA receptor encephalitis, how many neuro consult teams do you know of who will actually ACCEPT the patient on their service? If they're like the ones I'm familiar with, a psych patient is a psych patient and psych will keep the patient. I have seen acute strokes be "managed" on the psych floor with at most phone consultation from neuro. Same for chest pain. The end treatment is always exactly the same! Haldol or Zyprexa or you name it! Time and again I have seen psychiatrist deal with "medical problems" by doing what they do best, which is ordering psych meds. Raise your hand if you are a fan of benzos or clonidine for hypertension! That's only the beginning.

5) You have to do 4 months of serious internal medicine in psych residency.
- So not true. Many residencies know their residents aren't up to the challenge and make the off service months as cush as possible. I'm not saying this is admirable, but it happens.
 
I take issue with the "send the incompetent people to psychiatry, they can't mess anything up." I had a patient in the ICU s/p massive overdose after her psychiatrist told her there was "nothing more he could do to treat her depression." Yeah. There is a tremendous amount of good and a tremendous amount of harm that can be done by a psychiatrist. The wrong words from a trusted psychiatrist can send patients into a tailspin, can push them to end their lives, can lead them to harm others. The wrong judgement call from a psychiatrist such as an early or inappropriate discharge can lead to morbidity and mortality just as surely as a wrong cancer diagnosis.

I can just as easily dismiss a possible pathology slide misread - how much difference does it make if grandma's biopsy is read as DCIS vs the actual invasive ductal cancer that is present at age 85? Does it matter? Maybe she'd be better off with a misdiagnosis so hem/onc doesn't get unleashed on her. Half the time tissue gets sent for path for due diligence and the report gets read by precisely nobody.

Edit: Also, take a look at the SDN pathology forum for a refresher on this "hallowed and revered" specialty.
 
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LisaLou said:
In addition, you will be expected to be able to, say, follow JNC guidelines and start a stable patient on an appropriate initial medication for their hypertension.
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this may be the case in some academic centers during residency, but you really wont be doing this out in the community
 
shan564 said:
you need to be able to figure out when your patient's low mood is caused by uncontrolled hyperglycemia
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Euthymia said:
I think it may be harder for a lot of MDs to get where SMC123 is coming from, but as a DO, it is very understandable to me. A lot of us go through 3rd and 4th year without ever writing notes, talking to patients, coming up with differentials, workups, or treatment plans. Some of us spend our core rotations shadowing nurses and medical assistants or quietly observing a physician from the corner. It's only natural to feel completely incompetent. The thought of being thrown into residency where we are actually responsible for doing these things is terrifying to many of us, present company included.
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I've noticed that what DO's do in med school tends to be very variable. Some of the sites are ok, and then some of the rotations are in places where no core rotations should ever be.

At least with SGU and Ross grads you sorta know what hospitals you are dealing with. With DOs and the non-carrib imgs, no idea often.

I'd rather be a DO student than an SGU/ross student, but I would rather would with a ross/sgu student. All other imgs(including euro type imgs) I would take a DO above in terms of working with
 
SteinUmStein said:
I take issue with the "send the incompetent people to psychiatry, they can't mess anything up." I had a patient in the ICU s/p massive overdose after her psychiatrist told her there was "nothing more he could do to treat her depression." Yeah. There is a tremendous amount of good and a tremendous amount of harm that can be done by a psychiatrist. The wrong words from a trusted psychiatrist can send patients into a tailspin, can push them to end their lives, can lead them to harm others. The wrong judgement call from a psychiatrist such as an early or inappropriate discharge can lead to morbidity and mortality just as surely as a wrong cancer diagnosis.

I can just as easily dismiss a possible pathology slide misread - how much difference does it make if grandma's biopsy is read as DCIS vs the actual invasive ductal cancer that is present at age 85? Does it matter? Maybe she'd be better off with a misdiagnosis so hem/onc doesn't get unleashed on her. Half the time tissue gets sent for path for due diligence and the report gets read by precisely nobody.

Edit: Also, take a look at the SDN pathology forum for a refresher on this "hallowed and revered" specialty.
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Pathology is hallowed and revered! It's much older and more distinguished a science and specialty than psychiatry! (Even to make this statement I have to use the word "science" loosely since it so often doesn't apply in our field. Go look at the "therapy dog" thread for proof.) Without pathology we wouldn't have anatomy lab and basic causes of death wouldn't have been discovered! Pathology might be full of problems and have a bleak job market, but if I had to choose a specialty to throw overboard, or a tome of knowledge to eliminate, I would throw psychiatry and the DSM out before pathology and the Robbins textbook (or whatever its name is). You are being cynical with your example that a pathology slide misread for an 85 year old is unimportant. The equivalent in our field would be saying it doesn't matter if you discharge some drug addict and he kills himself - he would have died anyway. You wouldn't say that! Similarly I doubt you'd want your spouse or kid to not have their r/o melanoma biopsy correctly read if it came to that.

I agree that an incompetent psychiatrist can be a dangerous thing. Your example comes from the realm of psychotherapy and that indeed is a challenge of our field. Saying the "wrong thing" can be very harmful. My point was, diagnosing the wrong thing isn't what's going to harm that patient. Even the dreaded NMS, despite all the emphasis placed on "recognizing it" in psych residencies, is almost impossible to cause! I have seen people taking 100s of milligrams of haldol and they do ok. Even the more dreaded hypertensive crisis is nothing compared to an aortic dissection or conditions that other fields routinely deal with - and they have to diagnose them correctly and quickly. I'm sorry but in my opinion we are indeed a field where kindness and compassion can make up for a lot when it comes to differential diagnosis skills.

I am not going to say that it is absolutely unnecessary to be able to diagnose things in psychiatry, because again there are lethal conditions we theoretically deal with (ie. hypertensive crisis), but they are rare and not the most acute situations in all of medicine. So we have this buffer. Pathology does not have that buffer. They have to make correct diagnoses or they get sued.

If this psychiatrist really thought there was nothing more that could be done than he should have referred her to another provider or a more intensive form of treatment, and I doubt he actually tried "everything." But she wasn't in the ICU because he misdiagnosed her! In fact it sounds like he correctly diagnosed her! So his differential diagnosis skills are actually to be commended.

EDIT: Lest anyone think that just because I said I'd get rid of psychiatry before I'd get rid of pathology, that I'm "discounting the importance of psychiatry" - let me clarify this. I think psychiatry is important. But in a history of medicine textbook, no one is going to put an advance from psychiatry on the front page. We have had advances, but they have not been ones that have transformed all of medicine. Whereas without certain developments over the years - autopsies, antibiotics, anesthesia - medicine would be far behind what it is now. I know this forum tends to be extremely reverent towards psychiatry and I don't mean to offend anyone; but truly I cannot imagine modern medicine being what it is without pathology.
 
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