Most emotionally taxing specialty

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TwoHighways

TwoHighways

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Pediatric oncology? Palliative care? Psychiatry? Is it weird to desire that sort of burden when thinking about what field of medicine you’d like to go into?
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wanderingorion said:
What is the rationale of your desire?
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When I’ve personally experienced anguish and suffering, I’ve grown tremendously from it. I also believe what’s good in this world is amplified when we’ve experienced some really low points.

I’m introverted by nature. I value self awareness in a person more than just about any other quality/character trait. I’m fascinated by the human condition. Suffering seems almost universal to what makes us, us.
 
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TwoHighways said:
When I’ve personally experienced anguish and suffering, I’ve grown tremendously from it. I also believe what’s good in this world is amplified when we’ve experienced some really low points.

I’m introverted by nature. I value self awareness in a person more than just about any other quality/character trait. I’m fascinated by the human condition.
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I think this fascination is very attractive in the abstract, but when you're immersed in it later on, I doubt it will be as appealing.
 
My exposure to inpatient child psych was brutal. Emergency medicine didn't compare based on cases, but I could see myself hating patients after a short time.
 
TwoHighways said:
When I’ve personally experienced anguish and suffering, I’ve grown tremendously from it. I also believe what’s good in this world is amplified when we’ve experienced some really low points.

I’m introverted by nature. I value self awareness in a person more than just about any other quality/character trait. I’m fascinated by the human condition. Suffering seems almost universal to what makes us, us.
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The first noble truth. Are you the Buddha?

The thing about medicine is that no matter which specialty you choose, you will be a witness to immense suffering. The worst day of their life. But you know that from your paramedic experience.
 
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Yeah its weird. Your desire for emotional taxation won't last particularly long into your career.
 
AnatomyGrey12 said:
PICU.
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Heck no. PICU is dope. Sure there is some sad stuff but unless you are in an academic center dealing with all your kiddos on vents it’s actually quite enjoyable. Yes the child abuse cases are sad and the occasional deaths but It’s pretty awesome to see the kids come looking like crap but leave looking a million times better. I think the good balance of sad and happy outcomes make it not as emotionally taxing.
 
DO2015CA said:
Heck no. PICU is dope. Sure there is some sad stuff but unless you are in an academic center dealing with all your kiddos on vents it’s actually quite enjoyable. Yes the child abuse cases are sad and the occasional deaths but It’s pretty awesome to see the kids come looking like crap but leave looking a million times better. I think the good balance of sad and happy outcomes make it not as emotionally taxing.
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Eh perhaps. I'll admit I'm basing that off of my wife's nurse rotation in the PICU at a large academic children's hospital where a good amount of the kids who came in didn't leave.

My other suggestion would be peds onc.
 
AnatomyGrey12 said:
Eh perhaps. I'll admit I'm basing that off of my wife's nurse rotation in the PICU at a large academic children's hospital where a good amount of the kids who came in didn't leave.

My other suggestion would be peds onc.
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Its one of the only fellowships I could see myself doing. I loved my PICU rotations both at a community hospital PICU where it was a ton of DKA/child abuse/respiratory failure kids and my academic one where there were more ominous outcomes. So I chalk it more up to practice environment. Cause the threshold for PICU is low in some places, if a kid needs albuterol too frequently then they automatically go PICU even with a good prognosis.
 
raiderette said:
My exposure to inpatient child psych was brutal.
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Agree with this. Spent one of my weeks on psych on the inpatient peds psych ward and it was tough. All the girls were there for suicidal ideation due to molestation, abuse, bullying, etc. All the boys were there for antisocial or oppositional defiant (I don't remember which one is the one under the age of 18) and would scream and throw things all the time. Apparently, the outpatient aspect isn't as bad, just a lot of ADHD; but I couldn't stomach dealing day in and day out with things that I couldn't tangibly fix. Hence why I now do what I do.
 
Fibromyalgia clinic or POTS clinic - ridiculous patients, lots of internet experts, not a lot of treatment options.


Things with deaths involving children are pretty tough on most people...however, the outcomes in the PICU and even things like Peds Heme/Onc the like are pretty good compared to adults - i.e. PICU mortality rate is generally 3-4%, oncology outcomes for a lot of stuff have 5 year survival rates of >90% etc... and despite my protestations as a PICU attending, even the BMT and Neuro-onc folks assure me that their outpatient clinic kids are a joy to be around (which is decidedly not the case for those kids that end up in the PICU).
 
I love what I do but I do find psychiatry quite emotionally taxing. There are weeks that I feel more tired than I did in Intern year despite significantly better hours.

Having said that, it’s also a lot more satisfying for me because a greater percentage of the exhausting work seems to be direct impactful than it was on internal medicine wards. On medicine it just seemed like the most exhausting work was also the most meaningless.
 
BigRedBeta said:
Fibromyalgia clinic or POTS clinic - ridiculous patients, lots of internet experts, not a lot of treatment options.
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Gosh, we get these patients in psychiatry sometimes. They seem to be quaternary care referrals to my hospital after years of refractory symptoms. These are ridiculously difficult cases and for the people we wind up seeing (I.e. people with the resources to fly themselves across the country to get admitted), the honest answer of “this is going to require intense CBT and a lot of time” doesn’t seem to be acceptable.
 
sloop said:
Gosh, we get these patients in psychiatry sometimes. They seem to be quaternary care referrals to my hospital after years of refractory symptoms. These are ridiculously difficult cases and for the people we wind up seeing (I.e. people with the resources to fly themselves across the country to get admitted), the honest answer of “this is going to require intense CBT and a lot of time” doesn’t seem to be acceptable.
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Because it's not really acceptable. That used to be the answer for MS and Endometriosis. Christ, a few decades ago, the answer for UC was "lobotomy and Freudian analysis to deal with your mommy issues." CBT isn't going to change the results of a tilt table test.
 
TypeADissection said:
Agree with this. Spent one of my weeks on psych on the inpatient peds psych ward and it was tough. All the girls were there for suicidal ideation due to molestation, abuse, bullying, etc. All the boys were there for antisocial or oppositional defiant (I don't remember which one is the one under the age of 18) and would scream and throw things all the time. Apparently, the outpatient aspect isn't as bad, just a lot of ADHD; but I couldn't stomach dealing day in and day out with things that I couldn't tangibly fix. Hence why I now do what I do.
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It’s conduct disorder and then antisocial PD after age 18. ODD wouldn’t really put a child in inpatient psych


Also I think inpatient psych is wildly variable from extraordinarily depressing to pretty fun depending on where you end up - at least that’s been my experience.
 
MSTP18 said:
Because it's not really acceptable. That used to be the answer for MS and Endometriosis. Christ, a few decades ago, the answer for UC was "lobotomy and Freudian analysis to deal with your mommy issues." CBT isn't going to change the results of a tilt table test.
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You are right that we don’t cure these diseases with CBT. Nobody comes into the psych hospital expecting their fibromyalgia to be cured (well, I shouldn’t say that but at least they shouldn’t come in expecting this). The patients we see are not going to lead pain-free lives and that’s not the goal. The POTS people have all sorts of distressing symptoms, many of them behavioral. We work on what we can change.

Besides this, a good portion of these diagnoses are bull**** and are really rebranded psychiatric illnesses influenced by a patient in denial. I’m not saying they all are, but some definitely are.
 
sloop said:
You are right that we don’t cure these diseases with CBT. Nobody comes into the psych hospital expecting their fibromyalgia to be cured (well, I shouldn’t say that but at least they shouldn’t come in expecting this). The patients we see are not going to lead pain-free lives and that’s not the goal. The POTS people have all sorts of distressing symptoms, many of them behavioral. We work on what we can change.

Besides this, a good portion of these diagnoses are bull**** and are really rebranded psychiatric illnesses influenced by a patient in denial. I’m not saying they all are, but some definitely are.
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Of course the patients don't expect to be cured at the psych hospital. A lot of the doctors referring them on the other hand do think they'll be cured or that psychiatry is the best, most effective care we have to offer for these people.

I think we throw around "psychogenic" or "behavioral component" way to frequently. It's either latent misogyny or it's to absolve us of any guilt at being unable to diagnose or manage the patient. I've seen a few absolute horror stories in medical school of women (it's always women) who were being completely blown off because anxiety/depression is somewhere in the chart and instead they had things like small bowel obstructions, extensive adenomyosis, ruptured ovarian cysts and even ovarian torsion.

On the flip side, just had a frozen today for a guy who was operated on because he had a sore throat - literally no other symptoms - and a very distant history of stage 1 thyroid cancer. Turned out to be high grade esophageal cancer. The surgeon was like "wow, I am so lucky. I mean the guy just has a sore throat and nothing else so I almost didn't do anything but something about it just didn't feel right." The something was probably that it was a guy.

Getting back to the POTS/Fibro patients, of course they have psych comorbidities. Chronic pain is horrible and chronic nausea is even worse. The POTS patients are typically kids so they are having a normal childhood taken away from them. Many doctors will say the psych history explains/exacerbates the other symptoms. For some reason the idea that the medical history explains/exacerbates the psych symptoms isn't usually on the table.
 
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MSTP18 said:
Of course the patients don't expect to be cured at the psych hospital. A lot of the doctors referring them on the other hand do think they'll be cured or that psychiatry is the best, most effective care we have to offer for these people.

I think we throw around "psychogenic" or "behavioral component" way to frequently. It's either latent misogyny or it's to absolve us of any guilt at being unable to diagnose or manage the patient. I've seen a few absolute horror stories in medical school of women (it's always women) who were being completely blown off because anxiety/depression is somewhere in the chart and instead they had things like small bowel obstructions, extensive adenomyosis, ruptured ovarian cysts and even ovarian torsion.

On the flip side, just had a frozen today for a guy who was operated on because he had a sore throat - literally no other symptoms - and a very distant history of stage 1 thyroid cancer. Turned out to be high grade esophageal cancer. The surgeon was like "wow, I am so lucky. I mean the guy just has a sore throat and nothing else so I almost didn't do anything but something about it just didn't feel right." The something was probably that it was a guy.

Getting back to the POTS/Fibro patients, of course they have psych comorbidities. Chronic pain is horrible and chronic nausea is even worse. The POTS patients are typically kids so they are having a normal childhood taken away from them. Many doctors will say the psych history explains/exacerbates the other symptoms. For some reason the idea that the medical history explains/exacerbates the psych symptoms isn't usually on the table.
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....latent misogyny. What are you on about...?
 
MSTP18 said:
Of course the patients don't expect to be cured at the psych hospital. A lot of the doctors referring them on the other hand do think they'll be cured or that psychiatry is the best, most effective care we have to offer for these people.

I think we throw around "psychogenic" or "behavioral component" way to frequently. It's either latent misogyny or it's to absolve us of any guilt at being unable to diagnose or manage the patient. I've seen a few absolute horror stories in medical school of women (it's always women) who were being completely blown off because anxiety/depression is somewhere in the chart and instead they had things like small bowel obstructions, extensive adenomyosis, ruptured ovarian cysts and even ovarian torsion.
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We do try to work up medical issues if we think there's likely something physical that explains the symptoms. On the other hand, you're quoting dramatic examples and not seeing that a lot of these patients don't have a clear physical cause of their very vague symptoms. Either you're using extreme minority examples to justify million dollar workups on everybody or I'm not really sure what your point is. As a general rule people with fibromyalgia or POTS have vague symptoms that are not clearly indicative of anything in particular and have already undergone at least a moderate workup for other causes. To justify ongoing medical workup for these people, you need to think it is likely enough to yield something new and actionable to justify the cost of doing so both in terms of the expense of the tests and the therapeutic harm of increasing the salience of the symptoms should the workup be unrevealing.

On the flip side, just had a frozen today for a guy who was operated on because he had a sore throat - literally no other symptoms - and a very distant history of stage 1 thyroid cancer. Turned out to be high grade esophageal cancer. The surgeon was like "wow, I am so lucky. I mean the guy just has a sore throat and nothing else so I almost didn't do anything but something about it just didn't feel right." The something was probably that it was a guy.
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I don't really understand how the pathologist running the section feels qualified to pontificate about the motives of the person who sent the specimen, but whatever.

I don't know the details of this case, but if these were all the facts then it indeed sounds like the surgeon recommended an invasive procedure on something of a lark and, as he mentions, got extremely lucky. I don't think we should be making decisions about what we should or should not do based on this example.

Getting back to the POTS/Fibro patients, of course they have psych comorbidities. Chronic pain is horrible and chronic nausea is even worse. The POTS patients are typically kids so they are having a normal childhood taken away from them. Many doctors will say the psych history explains/exacerbates the other symptoms. For some reason the idea that the medical history explains/exacerbates the psych symptoms isn't usually on the table.
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The idea that the medical history explains their psychological state is always on the table. You're talking about a process that you clearly have minimal knowledge of.

The medical illness can explain the psychological state and the psychological state can explain the impacts of the illness. One or both of these things can be true in a given patient. It depends on the patient. If you're trying to explain someone's depression in terms of past life events/chronic medical illness when they have extensive genetic loading for affective illness and their mood symptoms are clearly syndromal and episodic, you’re being extremely foolish.
 
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I think living children who have been mentally and sometimes physically destroyed with no real hope of improvement is worse. I've done a few inpt child psych rotations, one at a state-run psych facility, where the majority of kids were in and out of the cycling door that is the foster/child welfare system. Some of the stories are bad enough that I've never even mentioned them to others. My wife used to occasionally ask me what my day was like (aka any interesting cases) until my child psych rotation when we had the following conversation (paraphrasing of course):

Wife: How was your day? Any crazy cases?
Me: Well, I had a 7 year old ask me if I wanted a blow job.
Wife: OMG! Why would she do that?
Me: She said her Grandpa used to tell her to do it to him then would buy her ice cream as a reward.
Wife: That's one of the worst things I've ever heard...(other comments about how awful that is)... I hope the rest of the day wasn't that bad!
Me: That was actually my easiest patient today...
Wife: *looks dumbfounded* What was worse than that?

I told her about 1 or 2 of my other patients who I won't mention here and she actually started crying. She told me she later that week she was barely sleeping because she couldn't imagine how anyone could do some of the things I talked about to another human let alone a child. She never asked me about child patients after than and still doesn't. I've had some child patients who were victims of sex trafficking/crimes and who have suffered through various forms of torture. It was a constant reminder about how horrible humans are to each other and many of those kids would have gladly traded a terminal illness for what they went through.

I've done rotations that included significant palliative/hospice care and treated cancer patients. I've had patients die, both suddenly and unexpectedly and slowly and painfully. It all sucks. But I honestly can't imagine working in a field with those kids for my career because there were moments that I almost felt like I was losing a part of my soul and I'm a psychiatrist.
 
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sloop said:
We do try to work up medical issues if we think there's likely something physical that explains the symptoms. On the other hand, you're quoting dramatic examples and not seeing that a lot of these patients don't have a clear physical cause of their very vague symptoms. Either you're using extreme minority examples to justify million dollar workups on everybody or I'm not really sure what your point is. As a general rule people with fibromyalgia or POTS have vague symptoms that are not clearly indicative of anything in particular and have already undergone at least a moderate workup for other causes. To justify ongoing medical workup for these people, you need to think it is likely enough to yield something new and actionable to justify the cost of doing so both in terms of the expense of the tests and the therapeutic harm of increasing the salience of the symptoms should the workup be unrevealing.



I don't really understand how the pathologist running the section feels qualified to pontificate about the motives of the person who sent the specimen, but whatever.

I don't know the details of this case, but if these were all the facts then it indeed sounds like the surgeon recommended an invasive procedure on something of a lark and, as he mentions, got extremely lucky. I don't think we should be making decisions about what we should or should not do based on this example.



The idea that the medical history explains their psychological state is always on the table. You're talking about a process that you clearly have minimal knowledge of.

The medical illness can explain the psychological state and the psychological state can explain the impacts of the illness. One or both of these things can be true in a given patient. It depends on the patient. If you're trying to explain someone's depression in terms of past life events/chronic medical illness when they have extensive genetic loading for affective illness and their mood symptoms are clearly syndromal and episodic is extremely foolish.
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I was not speculating the motives of the surgeon, he came to see the frozen himself. The part in the quote is pretty close to an exact quote.

Unfortunately I have very extensive experience in this area. I’m not talking about doing million dollar work ups on everyone, for a lot of these patients, a good history and physical is sufficient. I’m glad you’re so cognizant of all of this. Maybe it’s prexisely because you are psych. I’ve seen far too many colleagues who do not share your conscientiousness.

My point is that we need better awareness and better research so that these people DONT get million dollar workups and can actually get treated. I think also having more awareness of the history of medical research and seeing how many obviously “real” conditions used to be considered “psychogenic” is important and should make one cognizant of the idea that the same thing will happen in the next few decades and to keep an open mind.
 
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Quite a stretch to assume someone with your interests hasn't seen Being Mortal on Frontline.com. But it would be well worth the watch. Goes into some of what you're talking about. Great documentary
 
Philosopher Jagger said:
Quite a stretch to assume someone with your interests hasn't seen Being Mortal on Frontline.com. But it would be well worth the watch. Goes into some of what you're talking about. Great documentary
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I haven’t and will check it out.
 
TwoHighways said:
I haven’t and will check it out.
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It features Dr. Atul Gawande. There is also his book by the same name. The book especially delves into how docs deal with heavy emotional topics, death, palliative care, etc. I won't say "required reading" for physicians, but definitely recommended
 
Philosopher Jagger said:
It features Dr. Atul Gawande. There is also his book by the same name. The book especially delves into how docs deal with heavy emotional topics, death, palliative care, etc. I won't say "required reading" for physicians, but definitely recommended
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The most powerful part for me was around the 38:30 mark, when the gentleman with terminal brain cancer stated something along the lines of “I’d rather she pull a gun out and shoot me than listen to her try to be nice as she’s giving me more bad news.” She being his neuro-oncologist.
 
MSTP18 said:
I was not speculating the motives of the surgeon, he came to see the frozen himself. The part in the quote is pretty close to an exact quote.

Unfortunately I have very extensive experience in this area. I’m not talking about doing million dollar work ups on everyone, for a lot of these patients, a good history and physical is sufficient. I’m glad you’re so cognizant of all of this. Maybe it’s prexisely because you are psych. I’ve seen far too many colleagues who do not share your conscientiousness.

My point is that we need better awareness and better research so that these people DONT get million dollar workups and can actually get treated. I think also having more awareness of the history of medical research and seeing how many obviously “real” conditions used to be considered “psychogenic” is important and should make one cognizant of the idea that the same thing will happen in the next few decades and to keep an open mind.
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Sure, it would be great if there was an identifiable medical intervention that could save the day and alleviate all symptoms. But the sort of folks @sloop is talking about come to us after being run through the gamut and being given insane medication regimens that don't really help that much (but do have tons of side effects and abuse liabilities - chronic opioids, anyone?) but no one has ever asked them "so what would you do if these symptoms never get better?" Figuring out the answer to that question is what is going to improve quality of life until a miracle cure comes along.

Of course we treat MS and endometriosis to the best extent possible. But before the advent ofAdvent of effective meds and procedures for these conditions, treating the behavioral and emotional sequelae was absolutely what needed prioritizing. Even now, lots of people with endometriosis have recurrent and chronic pain post all the interventions available, and MS, even treated well, has sky-high rates of depression and even an elevated risk of psychosis compared to gen pop.

All experience of pain is generated in the brain, regardless of where peripheral nocioceptive signals may be coming from. Peripheral interventions only get you so far. To effect change beyond that, you have to change brain functioning, whether that is through meds or intensive therapies.

Too many people get stuck on the idea of suffering and become fused with the idea that nothing else matters and their lives must be put on hold until the suffering is eradicated. This keeps them from engaging with any of their valued or goals and, I would argue, reduced their quality of life in the long run more than anything else.
 
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