Internship

[koikisi]

I'm really feeling exhausted at this place I've started residency. I'm going to be anonymous and not give specifics as to the details of the place. I am doing more than 13 patients on the unit and psych is my first rotation.

It seems that schedule doesn't get any lighter as a 2nd and 3rd year either. I was wondering if anyone else is experiencing this? I feel like I'm just putting orders in without much guidance and support of an attending. I'm just googling things and figuring it out on my own.

I'm really nervous that I'm going to screw someone over and cause NMS or something, and in a few years my license will be gone. I just feel like the amount of time I would like to spend with these patients is minimal as well, due to the sheer volume we cover.

Just putting this out there to see if someone else is experiencing this. I really feel that therapy is an essential aspect of our job. We shouldn't just be shoving pills down people's throats. I can't do that if I have to constantly write notes on these people and discharge them.

I'm feeling very frustrated because I don't feel like I'm doing anything to help my patients just by knocking them out cold with benzos and antipsychotics. They'll just be back in a few weeks due to substance abuse.

I feel like voicing my opinion, but what's sad is that my training will never be more than just medication management. Because the attendings are frustrated with the patient population themselves.

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[wolfvgang22]

13 patients is a lot for a new PGY1 in July. Ideally you should only be seeing 4-6 patients this early in my opinion. Is the attending seeing the patients with you at all? Call or ask him or her every time you have a question, ask lots of questions up front, when you think of them. Better now than later. If the attending is an dingus about it, whatever, you'll eventually have a different one. You'll be an attending one day and everyone will know who the dinguses are, don't worry about that. If it is really bad, talk to your program director about it.
Can you get guidance from PGY2 or other PGY1? I found senior residents to be some of my best friends and mentors in training.

The good news is PGY1 is kind of terrifying for everyone the first couple of months. You'll get exponentially better with time, don't worry about that. I remember one of my PGY1 buddies calling and asking be about Ibuprofen dosing when I was a PGY1 and he was on call. Yes, Ibuprofen! We had a laugh about it later. He's an excellent attending psychiatrist now.

If you are nervous about causing NMS or something - good! This means you have a topic to read up on whenever you get a moment. This is what professionals do, they look things up and educate themselves. If you read you will eventually notice when attendings/other doctors are not practicing evidence based psychiatry. You will eventually know what to do when some others do not.

Usually you won't be doing therapy in inpatient psychiatry rotations. You are stabilizing patients with medication, so they can be discharged home relatively safely, at which point they can do psychotherapy if they want in an outpatient clinic and continue their recovery. The inpatient unit probably has some groups throughout the day for patients, and some patients may do some individual therapy. Why not more? Because many inpatients are very ill and not at a place where they can participate a lot in psychotherapy, and hopefully they won't be in the hospital very long - insurance won't allow long stays much these days anyway. Your job is not to do therapy right now. You traditionally will learn about therapy mostly when you do outpatient psychiatry in most programs. Yes, many of your sickest patients will be back in a week or two. Yes, there are many problems with the way we hospitalize people with mental illness and fail to help them avoid hospitalization after discharge. That is not your problem right now, though. Your goal right now is mostly to learn psychopharmocology, observe, and maybe you can contribute down the line to help solve these problems when your training is more advanced.

 

[splik]

sorry to hear that you are having a miserable time. presumably your co-residents are feeling the same way and it can be helpful to talk about this so you don't feel alone with this and recognize you are at sucky program and they are overworking you. 13 patients is ALOT to be starting with as an intern and it would not be surprising if you felt overwhelmed and tired. In terms of things not getting better - I am not sure it is helpful to think in that way - what a demoralizing thought! you may have a busy schedule in later years but you won't have medicine rotations, AND you will be different. You will be surprised what a difference even a month can make. You learn more during your first month of residency and your first experience of nightfloat than at any other time. Now, it isn't ideal that you apparently don't have great supervision or mentorship but you will get much quicker as the year goes on. PGY-2s are twice as fast as PGY-1s and PGY-3s twice as fast as PGY-2s (per a report on residencies by the RAND corporation). You will get quicker at writing notes, write less, learn how to prioritize tasks, become efficient, do a target quick-fire interview on rounds etc. Trying to find some time to do what you enjoy and spending time with friends or family can also be helpful.

As wolfgang says, it's very unusual for psychotherapy to happen in the inpatient setting these days, and very few programs (typically only the top programs) have residents learning something of psychotherapy on their inpatient rotations. However you will hopefully learn about psychotherapeutic skills including motivational interviewing later in your training. At that point you will learn how to become more effective at working with your challenging patient population and may find the work more gratifying

There is a difference between doing psychotherapy and being therapeutic. Your job will become being therapeutic. But at this point your job is to master the basics of organizational skills, note/discharge summary writing, doing brief daily assessments including MSE/risk assessments and learning the basics of management of acute. You are also probably learning alot about sitting with difficult emotions, and listening (or not) to patients without realizing it.

Inpatient psychiatry isn't for everyone. I hated it too as an intern. It's actually less painful later on when you do have more skills and have a better grasp of working effectively with borderline/antisocial/substance abusing patients

I will also mention that it is an ACGME requirement that you have 2 hours of supervision a week on inpatient rotations, and at least one hour of supervision with your attending. You should remind your attendings of this (as they may forget or blow it off otherwise) and take it up with your PD if there are issues.

Also 4 years is actually a very short time, and you can always fast track into child psychiatry or public psychiatry fellowships if you want to get away from your program earlier! Once you are finished you can practice how you like and unlearn all the bad stuff that you were exposed to. You could also consider doing a fellowship at a better place in order to get a more positive training experience. Or you could consider transferring out for next year however your chances are probably not that great if you weren't competitive in the first place

 

[Shikima]

Think of your exhaustion as a good sign that you're doing good work and doing a lot of thinking rather than just blinding doing whatever and not caring. You're brain is processing a lot and it's exhausting with so much to learn, think and keep track of and you need to sleep as much as you can. Keep it up!

 

[koikisi]

thank you all for your kind words. It was of some encouragement. I am afraid to mention things to my PD since he is a very loose tempered and labile individual who thinks he did me a huge service by offering me a spot in his program. He is very bossy and wants things his way, doesn't care about residents input at all.

But regardless, the one saving grace is the nice chief resident. The commens u guys are making are also true, psychotherapy isn't going to be a big factor in the inpatient setting.

I am having a lot of second thoughts about staying in the program due to the instability of the faculty. I was a reasonably competitive candidate who didn't plan well. But I honestly thought this was a great pgm before coming. I'm pretty disappointed by a lot of things and I think I'm going through an adustment disorder type of situation.

Can I really hate my life this much for the next 3-4 years? I mean it's utter chaos here without residents.

I spread myself too thin by switching from FM to Psychiatry half way through app season.

Oh well..

 

[koikisi]

..it's just way too busy and everyone is overworked....the PGY3's and 2's look like they are about to have a mental breakdown any minute.

My co-residents are also fed up, but most of them have done Psychiatry in their home countries so it's not a huge deal for them.

 

[koikisi]

I honestly am starting to think that I am just slow. My co-residents are able to do med rec's, discharge summaries in a matter of minutes on the EMR. I try and do a thorough and complete job, then I get yelled at by my seniors because they had to answer a page due to my errors.

My program director is also an attending since a few of the attendings have cut back and left. So this is my first in-patient Psych month, and I have to round with him and he really gets ticked off at me because of my inefficiency with patients and writing complete notes. Especially with regards to legalities of how long one can be held.

Honestly, I think the experience level between me and my colleagues is quite thick. I just graduated medical school this past June. I did not have much experience preparing discharge summaries, I never did them, I never ordered labs. Honestly, I was never expected to type up notes as a medical student since we were not afforded EMR priveleges. In fact, most of the time, I just wrote them.

I think the institution where I am at though, expects 3rd year medical students to be mini-interns. They probably assumed my DO school provided me with similar quality rotation experiences. I just feel that the level of proficiency that my colleagues have, who did Psychiatry research in India and did bserverships here, is quite superior to mine.

They do mental status exams, with good articulation in a matter of seconds. Yet, I struggle with the basics.

I think my anxiety level is quite high as well since I am struggling so much and i don't have good articulation and speech when presenting. The PD brings this up repeatedly and tells me that I'm doing an inadequate job especially compared to the 3rd year medical student. He really just is a very hostile person, and says that the only strength I have is that I don't have a problem with the English language (I'm 3rd generation Latina-American)

I know that the system is quite unforgiving to transferring or quitting, so I am just hoping you guys can give me some coping tips to use with this man. He doesn't seem like an evil person, but he is definitely quite harsh.

 

[MacDonaldTriad]

I did not have much experience preparing discharge summaries, I never did them, I never ordered labs. Honestly, I was never expected to type up notes as a medical student since we were not afforded EMR priveleges. In fact, most of the time, I just wrote them.

I just feel that the level of proficiency that my colleagues have, who did Psychiatry research in India and did bserverships here, is quite superior to mine.

I am struggling so much and i don't have good articulation and speech when presenting. The PD brings this up repeatedly and tells me that I'm doing an inadequate job especially compared to the 3rd year medical student.

I know that the system is quite unforgiving to transferring or quitting, so I am just hoping you guys can give me some coping tips to use with this man. He doesn't seem like an evil person, but he is definitely quite harsh.

If these things are true, you are trained at the level of an MS-III, but don’t be ashamed. Lots of interns show up at highly varied degrees of experience and if I have learned anything, it is that where you start does not predict long term outcome. I suppose someone who was afforded all advantages and learning opportunities and was still at the bottom of the curve would predict a poor outcome, but many a fine resident was produced from the most modest of starts. If you maintain effort, and a reasonable attitude with an acceptable IQ, you will catch up and probably pass many of your classmates.


Four years is both a very long, and a not so long period of time. Right now most directors are walking around saying: “when did you learn how to do that?.. What do you mean you are a PGY-III, when did that happen.” It is like that camera on the space shuttle that shows the earth getting smaller and smaller as it takes off. I’m staying the same and everyone around me is getting younger and younger and younger. My perception of time has become: birthday, graduation, birthday, graduation, birthday, (ACGME visit), graduation, birthday, …..


Hang in there and keep trying. It isn’t your altitude, it is your slope. Transferring or quitting will not be your solution anyway.

 

[koikisi]

If these things are true, you are trained at the level of an MS-III, but don’t be ashamed. Lots of interns show up at highly varied degrees of experience and if I have learned anything, it is that where you start does not predict long term outcome. I suppose someone who was afforded all advantages and learning opportunities and was still at the bottom of the curve would predict a poor outcome, but many a fine resident was produced from the most modest of starts. If you maintain effort, and a reasonable attitude with an acceptable IQ, you will catch up and probably pass many of your classmates.


Four years is both a very long, and a not so long period of time. Right now most directors are walking around saying: “when did you learn how to do that?.. What do you mean you are a PGY-III, when did that happen.” It is like that camera on the space shuttle that shows the earth getting smaller and smaller as it takes off. I’m staying the same and everyone around me is getting younger and younger and younger. My perception of time has become: birthday, graduation, birthday, graduation, birthday, (ACGME visit), graduation, birthday, …..


Hang in there and keep trying. It isn’t your altitude, it is your slope. Transferring or quitting will not be your solution anyway.

I know, I can't transfer or quit, my boyfriend has already found a job nearby as well.

It hurts to be the one that gets yelled at and picked on all the time, but I'm trying to create an environment conducive to learning.

 

[MacDonaldTriad]

No one who is honestly trying and can demonstrate effort deserves to get yelled at for very long. One bad rotation does not characterize a program, but seek out those above your tormentors if you feel the criticism is unwarranted and you can back this up. I would wait and meet more than one of two mentors before I dive into this high stakes game. Hang in there and good luck.

 

[koikisi]

No one who is honestly trying and can demonstrate effort deserves to get yelled at for very long. One bad rotation does not characterize a program, but seek out those above your tormentors if you feel the criticism is unwarranted and you can back this up. I would wait and meet more than one of two mentors before I dive into this high stakes game. Hang in there and good luck.

I don't know who my mentor is. They haven't provided me with one. The PD is quite rude to me whenever I talk and always makes a point to insult me in front of the other interns and medical students by saying " You are seriously not done with that?" You don't know that medicare doesn't cover this? Don't you know how to call someone when they page you?

I feel like I'm on the radar constantly. I feel like I am going through Adjustment disorder myself as well as the culture shock and nature of my co-interns has also left a sour taste in my mouth.

I believe in helping my peers and trying to share things with them. However, it seems that any type of helpful resource (doing a better mental status exam), templates for EMR, is hogged by a few members of the group. Everything is so damn secretive which drives me nuts. They speak their own language ( I don't know what it is but it seems some dialect of an Indian language) whenever I'm around and laugh uncontrollably. I mean they don't have to be so rude if I'm just standing there and they can at least tell me what the issue is.

Anyhow, I am doing my level best. I am getting to the point where I am starting to consider just resigning and giving up on my career. That's literally how low I feel after what I've encountered on the last couple of days. My attending says that they would like to have a meeting with me to discuss my inefficiency with discharging patients and duty hours. He says that "he doesn't know how DO school's teach students to put in orders, but clearly someone told you the wrong thing."

He says that I did not do an observership at the program and still managed to get in, and he thinks that I should have done an observership before coming so that they would have been acquainted with my performance. He says that the 3rd year medical students are more efficient than I am and know more about pharmacology and treatments than I do.

 

[InvegaSustenna]

Doesn't sound like a very supportive environment. You should PM me what program you are at so that I don't bother applying there. PD sounds like a douche. I'm sorry you're going through this. If it doesn't get any better, perhaps you could go somewhere else for pgy2?

 

[VMSmith]

Wow. What kind of PD treats an intern this way two weeks into the year?

 

[Shikima]

There are plenty of bad 'administrators' out there.