My unbalanced view of psychiatry

[PittBoo50]

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During one of my recent interviews, I heard very positive stories of how respected, worthwhile, and lucrative psychiatry could be if practiced in that area. I have rarely heard the words “respected” and “lucrative” used to describe the field.
It really got me thinking…My frame of reference is very partial. I would use the word “gritty” to summarize the psychiatry exposure I’ve experienced thus far: very limited patient resources, abundant malingering, with the majority of patients being dual diagnosis. The hospital system that I’ve rotated through for the past two years has conveyed disregard for these patients AND for those who choose to provide mental health-care. I had always assumed that this was the norm.

I would love to hear about other peoples’ experiences and opinions:

What kind of exposure have you had to psychiatry? Has it been “gritty”?

And how much does the location/patient population of your residency program, influence your future practice? If I were to train in an underprivileged location, is it likely that I could eventually practice in a more affluent area (or vice versa)?

 

[Anasazi23]

It seems that the psychiatry experience is largely dependent on the location of where you're working. Any city program, for example, is going to have its touch of "grittiness." The upside to this is that (unless you're in the inner city portion), you'll see a wide variety of patients. I can attest to this being in a downtown NYC hospital. I see everything from Wall St. bipolars, to 21 yo white NYU students with eating disorders, Village artists with first breaks, to homeless drug addicts and malingerers. More affluent area private hospitals will likely have a more 'upper echelon' subset of patients.

It is aggravating to see resources wasted and your own health suffer at times when you're up at 3am evaluating the third malingerer - but that is the nature of the job at times.

I can definitively tell you that no matter what type of residency program you graduate from, you can eventually practice with the type of population you prefer. Working in an inner city low quality hospital will in no way dictate that you must stick with that patient population if you do not choose to do so.

 

[cleareyedguy]

I'm surprised if you see 3 malingerers in an evening.

There are differences, for example, among somatoform disorders, factitious disorder, malingering, and substance abuse, though these do often coalesce to varying degrees within any individual patient. One of the reasons that therapy training is vital for psychiatry training is to help manage countertransference and premature closure and to increase the likelihood that each patient becomes interesting based not so much on their deservedness but rather on your ability to offer care, provide a sophisticated evaluation and intervention, and hone your own technique. Anyone who tries to reduce psychiatry to some sort of DSM/psychopharm machine is missing the boat.

By the way, it is easier to teach and test for subject-based competence than for observational and process competence, but that doesn't mean that the latter types of skillsets aren't more central to what it means to be a psychiatrist. That's true if you want to be a high-priced Park Avenue analyst or if you want to remain sane as a gritty inner-city psychiatrist caring for the homeless.

 

[PsychMD2100]

PitBoo50,

I can relate to your situation. My med school also has a psych department that isn't taken as seriously as, say, the surgery department.

However, as I've interviewed over the past couple months, I've started to sense how much variation there is. I think many people from my med school look down upon psych because of our department's place in the medical hierarchy.

As I've toured other hospitals, it's refreshing to see some programs where psych is among the most respected departments. Some places have psychiatrists as the med school dean, director of GME, or CEO of the hospital. At a few places, psychiatry is a top winner of research grants and brings in some of the biggest clinical revenues.

As I'm going through this process, I realize that my med school experience doesn't have to define my future as a psychiatrist. I'm consciously making an effort to have a residency experience that is different and more fulfilling than my med school one.

 

[whopper]

As Anasazi stated, it does highly vary.

If you're in a small rural town, most people with psyche issues you'll see are probably real, and will probably be a non substance abuse issue. E.g. depression, bipolar, psychosis, interfamily/personal conflict

If you're in a big urban city you'll see a lot of homeless, malingerers, people with personality disorders and they consult you just because the patient is difficult.

Some people do look down on psychiatry. Screw them. You don't pick the job you pick because some ignorant idiot looks down on it. Besides several docs I know in fields that people look up to have major problems because of the field. E.g. a surgeon working 80 hrs a week, is on his 4th marriage, doesn't know his kids.

My suggestion is if possible, try to get as much diversified exposure as you can so you can handle psychiatry anywhere you want to be. E.g. my own program has a city hospital and you do a lot of outpatient in rural & urban areas so you get a good mix of both.

 

[Chewbacca Jung]

I think malingerers are interesting. When you walk a little on the empathic side of life (not to be confused with the enmeshed side of life) you can see a whole new world open up. It's kind of fun to walk a little bit in someone elses shoes for a half hour, and then give them back-- and of course reject their request for more narcotics. It beats runny noses, hemorrhoids, and colostomy bags any day. I think to like psych, you have to relax your sphincter and enjoy your patients. You have a chance to intervene with people that no-one else wants to or can deal with. anyway, that's my two cents.

 

[Dartos Vader]

I think malingerers are interesting. When you walk a little on the empathic side of life (not to be confused with the enmeshed side of life) you can see a whole new world open up. It's kind of fun to walk a little bit in someone elses shoes for a half hour, and then give them back-- and of course reject their request for more narcotics. It beats runny noses, hemorrhoids, and colostomy bags any day. I think to like psych, you have to relax your sphincter and enjoy your patients. You have a chance to intervene with people that no-one else wants to or can deal with. anyway, that's my two cents.

I totally agree. That is one of the best parts. There's a whole culture of people out there who don't "play by the rules" of normal society. It's kind of cool to dive into that world every once in a while (and then jump out at the end of the day).