New intern on Psych inpatient soon. Tips/advice please?

[Central_SOULcus]

Hello everyone,

I'm a new Psych intern and will finally be starting my first inpatient Psych rotation at the end of this month. I'm VERY excited because I absolutely love psychiatry, and so far, I'm loving my program too. I would very much appreciate any advice about how to do well on inpatient psych, as an intern. (I know there are many threads on this already, but I haven't really found one that is more recent and is specific to inpatient psych.)

A bit about me: I feel incredibly fortunate to be in residency and want to become an excellent psychiatrist for my future patients. I'm in my mid-thirties and medicine is my second career, so I'm comfortable showing up on time, working hard, being a team-player, and taking criticism. Other than those bare minimum qualities, what else can I do to most help my seniors/Attendings? I would love specific examples. Thank you!!

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[OldPsychDoc]

Depends on the types of patients, acuity, and pace of turnover--all of which vary tremendously between units and hospitals--but here's what I love about my interns:
1) they own their patients. They know they don't always know what to do or what to say or how to say it yet, but they consider the patient assigned to them as theirs, and use their attending as a consultant.
2) they study their patients. They do the chart review I haven't had time to, they look for those records from other sources, they know more about the patient's past history than I do. They call collateral, they communicate with outside physicians, they chat up family members when they visit. I'd rather have an intern following three patients in depth than scrambling to keep up with six and doing a superficial job.
3) they're good people to have around. They have a sense of humor, they smile a lot, they treat nurses and NAs respectfully (and understand that those folks know more about our job than they do right now!). They appear to be enjoying this new job most of the time.
4) they know what they don't know--they ask questions a lot, they're engaged.
5) they're kind--to patients, to staff, to each other, to me

 

[uhmocksuhsillen]

Depends on the types of patients, acuity, and pace of turnover--all of which vary tremendously between units and hospitals--but here's what I love about my interns:
1) they own their patients. They know they don't always know what to do or what to say or how to say it yet, but they consider the patient assigned to them as theirs, and use their attending as a consultant.
2) they study their patients. They do the chart review I haven't had time to, they look for those records from other sources, they know more about the patient's past history than I do. They call collateral, they communicate with outside physicians, they chat up family members when they visit. I'd rather have an intern following three patients in depth than scrambling to keep up with six and doing a superficial job.
3) they're good people to have around. They have a sense of humor, they smile a lot, they treat nurses and NAs respectfully (and understand that those folks know more about our job than they do right now!). They appear to be enjoying this new job most of the time.
4) they know what they don't know--they ask questions a lot, they're engaged.
5) they're kind--to patients, to staff, to each other, to me

How much of this would apply to a medical student on a sub-i? What I mean is, are the standards essentially the same?

 

[Central_SOULcus]

Thank you for your thoughtful reply, @OldPsychDoc! I am at an academic program in a major metropolitan area. Many patients at my main hospital are uninsured/underinsured (this is the type of patient population I got into medicine for). As for nurses and NA's, my mom is a nurse and I grew up watching how hard she worked and how much she loved her job, so I have nothing but immense respect for nurses and all the staff really. I know that as an intern (and a brand new one at that) I know very, very little. I'm a little nervous but also looking forward to soaking up as much as I can!

 

[OldPsychDoc]

How much of this would apply to a medical student on a sub-i? What I mean is, are the standards essentially the same?

The attitude applies in full. You're not expected to take as much ownership/responsibility of patients as a resident would, though. (But you can pretend...what would you do if you were in that position?)

 

[NickNaylor]

Residents that are successful in my experience - and this applies equally to interns - have the following qualities:

1) They work hard. Understand that this means that, initially, you will likely be slow, and the time required to do basic tasks will take some time. You will get faster as you progress through your training.

2) Agree with @OldPsychDoc as above in the sense that they take ownership of their patients. While the attending is supervising, taking the approach of "the attending will take care of ____" is not a good approach.

3) They attempt to learn and understand why certain decisions are made, and they are curious about treatment plans. They will have a discussion with the attending about why a specific plan was chosen vs. another potentially reasonable plan.

4) They are trainable and respond to feedback. I think this is probably the most important point. You are not expected to be perfect, you are not expected to know everything, and you are expected to make mistakes. However, the important thing is that they hear feedback and makes changes to prevent the same mistakes from happening again. About the worst thing you can do is get defensive or otherwise try to explain why a mistake isn't your fault. Explaining why you did or didn't do something - if a "mistake" was intentional - isn't unreasonable. That's more of a discussion along the lines of #3 rather than a true "mistake." But if you screw up, own up to it, hear the feedback that you get, and figure out how to not do it again.

I'm junior attending on one of our units and am currently "supervising" our two new interns. Of course their fund of knowledge is weak and of course they don't know a lot of the processes with respect to getting things to happen. I wouldn't expect anything different. What makes them great interns, though, is that they are teachable, respond to feedback, and work hard. The knowledge and learning the processes of various hospital systems will come with time. The innate characteristics of a strong work ethic and a desire to learn and always improve are more critical.

 

[UTsksk]

I'm an intern who just finished my first week on inpatient psych. I think the key from what I've seen and what the uppers have said is to know the legal status and how it works in your state (I'm from a different state and it's different than the one I'm in now), patients are usually frequent flyers so look at prior admissions

 

[DisorderedDoc417]

I think the above information is great. If possible, this would represent an excellent resident. I do think that some of it, depending on your program, is more idealistic than realistic. Personally, I set standards such as those stated above and attempted to apply them to my PGY-1 year. At our program, we are following 2 new and 6 prior admissions daily as PGY-1 (3 and 8 respectively as a PGY-2). If patients discharge, we pick up new prior admitted patients and so you're constantly seeing 'new-to-you' people/things stay consistently busy. When this is the case, I think it becomes difficult to "know your patients better than your attending does". Especially if this is the patient's 7th admission and the attending knows them better than most outpatient psychiatrists know their own patients. In general though, I think my predecessors have submitted excellent advice, here are a couple of my cents (in addition to what has already been submitted) as I reflect upon the completion of PGY-1.

1. Be **honest** --- Sometimes you will forget to do something. Own it. There is perhaps the short-term success of faking something or telling a small fib, but losing the respect of your colleagues and superiors is far too great a risk. Swallow your pride.
2. Be timely, be kind to others. Nurses? They save your hind end at 3AM when the patient complains of painful flatuation (or they can make your life a living hell).
3. Try your best. You won't be good at your job --- and thats okay. They wouldn't make you do it for 4 years if competency was expected on day 1.
4. Ask for help when you don't have the answer, and ask for support or clarification when you *think* you do know the answer. Communication with the team will always be a win.
5. Be nice to those med students you will work with, because not so long ago you were sitting in their position... picture that resident you loved and do what they would do when it comes to med students.
6. Read. Read for fun. Read about zebras like anti-NMDAR encephalitis, read about the bread and butter depressions/anxiety/PTSD, read about assessing capacity. 60 minutes a day is a good place to start.
7. Treat yourself well: Eat well, sleep well, and do your best to be well.

 

[Onions]

I'll throw mine onto the heap: take pride in your work.

To give you an example of what I mean by this: let's say you're on call and the time comes to hand off to the next resident; did you clean the place up? Or are you passing work along? Sure, there are times when you have to pass things along, everyone understands that. But there are residents that make it their business to figure out how to legitimately pass on as much work as possible and do as little as possible themselves--and then there are residents that take pride in the fact that they're handing off a clean slate. Being the latter will 1) increase your clinical exposure and 2) give you more practice with handling workload, hence making you more efficient. You'll stay late a lot, but it's worth it. We're all here to learn and grow after all.

I write up all my evals in word documents that I save in a personal file on the hospital computer system, then copy paste them into the EMR. As such, I have a repository of hundreds of biopsychosocial write-ups that I've done. I feel proud of that: it's a nice volume of cases for each one of which I took time and gave careful thought. It's a nice way to look back on your work and have a roughly quantitative measure of your experience as a clinician.

 

[Throwawaywoop]

New psych intern here who started on inpatient last week as well; all of this advice is really helpful. Those who responded: how long would you say it took your interns before they really owned their patients, had a good sense of their patients’ past histories, worked well with the flow of the unit, all of the things you mentioned? It’s day 7 for me, and I still feel quite overwhelmed and like I was much better at these things as a sub-I last year than I am now. Granted, I was following 4 patients as a sub-I in a system I was familiar with compared to being fully responsible for 7-8 now as an intern, but I feel soooo bad about struggling to keep track of and have a good grasp on all of the patients in my census. I feel like it's interfering with my ability to provide my best patient care. I get that juggling multiple patients takes time and practice, and I'm aware that I'm still to some degree getting used to a new hospital system with a different patient population, new EMR, different workflow, etc. I know where I can improve and what my strengths are, and my attending and I have been communicating on this. But I can't help but feel like this last week of struggling was such a waste and that I have just about 2 and a half more weeks to make up ground and kick ass before switching teams. I'm worried about how I measure up compared to the other interns, one of whom is on service with me and seems to have his **** somewhat together, and the others, who will rotate through inpatient later in the year when they're on a better footing than I am now. I don't want to get the reputation of being a problem intern. I can't tell if this is normal or if I'm doing worse/struggling more than the average intern should be on day 7.

Sorry, this ended up being kind of a disorganized rant. Former interns, especially those who started on inpatient, how long did it take before things started to click?

 

[DisorderedDoc417]

It is a marathon, not a sprint. You will get faster. You will stop focusing on irrelevant factoids that make it difficult to recall important information. That stuff takes time, report back in 6 months.

 

[Onions]

I also had the uncomfortable experience as a PGY-1 of a strange, unfamiliar, numb, almost depressive sensation that took over some time around the 2nd or 3rd month of residency and lingered on into late winter before it lifted spontaneously. I thought I was the only one, but I talked about it with some of my co-interns and nearly all of them nodded their heads in agreement.

At its worst, I had trouble getting my day started in the mornings. I'd stare at my computer screen and not want to move. I would go find a quiet place, like the call room, close the door, shut the lights, and do a 2-minute plank on the floor, and then sit and do an 8-minute concentration meditation where I'd focus on my breathing. I did this exercise every day for several months early in residency and it helped me to get my day going. The dense amotivation and slow inertia of my mornings would usually lift by around noon or 1pm every day. I didn't talk about it with anyone until later because I thought I was just being a weirdo sneaking off for 10 minutes each morning.

Upon reflection, I suspect that once the initial novelty of carrying responsibility for patients began to wear off, I found myself up ****'s creek without a paddle in terms of managing my own feelings toward patients and the projective identification that seemed to be recapitulating in myself their anxieties and maladaptive thinking patterns.

I figured I should find a therapist at that time, but didn't. I should have. It ended up just being a matter of time before I had gotten a feel for the right boundaries that would allow me to keep a safe distance from "the work" (ie, the patients) without compromising my sense of empathy and therapeutic affirmation. I look at this process in retrospect like a sailor bumping into the rocks a few times because there's no lighthouse on shore. You have to explore the coastline before you can make an accurate map of it.

I dunno. Did any one else go through anything similar?

 

[hallowmann]

I also had the uncomfortable experience as a PGY-1 of a strange, unfamiliar, numb, almost depressive sensation that took over some time around the 2nd or 3rd month of residency and lingered on into late winter before it lifted spontaneously. I thought I was the only one, but I talked about it with some of my co-interns and nearly all of them nodded their heads in agreement.

At its worst, I had trouble getting my day started in the mornings. I'd stare at my computer screen and not want to move. I would go find a quiet place, like the call room, close the door, shut the lights, and do a 2-minute plank on the floor, and then sit and do an 8-minute concentration meditation where I'd focus on my breathing. I did this exercise every day for several months early in residency and it helped me to get my day going. The dense amotivation and slow inertia of my mornings would usually lift by around noon or 1pm every day. I didn't talk about it with anyone until later because I thought I was just being a weirdo sneaking off for 10 minutes each morning.

Upon reflection, I suspect that once the initial novelty of carrying responsibility for patients began to wear off, I found myself up ****'s creek without a paddle in terms of managing my own feelings toward patients and the projective identification that seemed to be recapitulating in myself their anxieties and maladaptive thinking patterns.

I figured I should find a therapist at that time, but didn't. I should have. It ended up just being a matter of time before I had gotten a feel for the right boundaries that would allow me to keep a safe distance from "the work" (ie, the patients) without compromising my sense of empathy and therapeutic affirmation. I look at this process in retrospect like a sailor bumping into the rocks a few times because there's no lighthouse on shore. You have to explore the coastline before you can make an accurate map of it.

I dunno. Did any one else go through anything similar?

Everyone I know in residency (psych or otherwise) had an experience of mild-moderate burn out like this between ~Sept/Oct-Jan of their first year. Its pretty normal, and from what I hear it goes in cycles. Here's to hoping 2nd year is better.

 

[pizzicarella]

Psych nurse here! I want to say a big thank you to everyone who has said to be considerate towards us nurses. Don't be afraid to ask us for information on paperwork, patient information, collateral, and standard-ish clinical work like patient interviews etc - generally we're spending quite a bit more time with each individual patient than any of the doctors are able to, so we usually have very good knowledge of baseline behaviour for individuals and how they're going on a given day, we'll have met with families, organised the day programs, and often you'll be basing your reports on assessments we've completed - so please ask us questions!