Non-psychiatry elective rotations in medical school

[st2205]

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This has been a recurring thread each year and every time a few new thoughts are shared but I think it typically goes unanswered because of how many times it's been brought up over the years. A lot of the common rotations continue to get mentioned as being high yield and occasionally some pop up with an argument of why they think one particular rotation may be beneficial to do an elective in. I've tried to give pretty serious consideration to my fourth year schedule and tried to focus on the bigger picture of getting pretty broad exposure in medical school, so I'd like to share different things of what I considered in making decisions so that maybe it can help anyone give consideration to certain electives and possible objectives which they may have not thought about previously. This comes with a caveat that I'm currently a third year student (who obviously hasn't done any of these electives yet) and so my assumptions about some of these electives may be completely off-base, but alas random spattering of information I collect from others above me is the only thing I really have to go on.

On of the things I considered in exploring electives is that it is oft mentioned of being familiar with vague symptoms and complaints (an argument of why ER and primary care rotations are beneficial), which seems to make a decent amount of sense. In conjunction with this, because vague complaints have a large overlap with psychological interpretation and/or psychiatric manifestations, I would consider it imperative to be able to have a decent understanding of each organ system to evaluate, either by history or physical, whether something is more serious and needs workup/referral or if the symptoms are exacerbating by primary psychiatric diagnosis. The continuing theme from residents and attendings has been echoed about being a well-trained physician first. I think the goal with a lot of electives may not necessarily provide huge benefit in understanding that field per se, but developing, in general, stronger H&P skills in each particular area of medicine can help in being more attuned to observation (i.e. learning how to look at skin on derm and being more sensitive to seeing manifestations of abuse or from an ophthalmology rotation being able to more naturally look at someone's eyes and make quick judgements -- when evaluating a psychotic patient with Wilson's disease).

Between all the different subspecialties, settings and practice options in psychiatry the argument can likely be made for just about any rotation to be somewhat relevant. With that in mind, and with schools requiring selectives from specific areas, I've assembled this by larger encompassing fields to break it down by so that people may have a resource for understanding their options.

Quasi-mandatory (I'm not going to give explanations on why to do these as it should be rather obvious)

ICU
Neurology
Emergency medicine
Cardiology

Internal Medicine

Cardiology: See above.
Gastroenterology: Abdominal pain can be a rather nebulous symptom with many psychiatric connections, but an underlying GI pathology may or may not be present and would warrant competent skills on the part of the provider to understand when more evaluation may be necessary and also to reasonably exclude pathology.
Endocrinology: Aside from numerous endocrinological problems having psychiatric manifestations I believe having the time dedicated to focus in a bit on diabetes, which you will encounter daily, would be beneficial to understand much more than the routine approach of primary care.
Nephrology: Fluids and electrolytes important for any physician. Understanding F&E with mental status changes in a consult setting. HTN as well in a general sense. Also lithium nephropathy.
Infectious Disease: Pretty relevant for CL. Many infections causing encephalopathies, in addition to any other encephalitis, may be pretty important to know the big picture before you can step in as a consultant on such issues.
Heme/Onc:
Rheumatology: Fibromyalgia. Also exposure to SLE patients. Most certainly don't want to miss lupus when you see it.

Surgery

Urology: Incontinence, ED and other sexual dysfunctions. As an outpatient psychiatrist and especially a psychotherapist may encounter these issues frequently and could benefit from understanding the harder (no pun intended) diagnosis, management and treatment of both functional and pathological problems in urology.
Otolaryngology/ENT: May not have a whole lot of relevance, but tinnitus, vertigo and the approach to HA may be useful to know.
Plastic Surgery: Get to see histrionic PD -- not that you would do a rotation to do such or that you would really want to. Also, it will give you an opportunity to develop good aesthetical suturing so that when you're an intern and you stitch up that borderline that cut themself you can do such a wonderful job in minimizing scarring that the pt will not have as great an opportunity to use the scars for attention-seeking behavior (ok, this one's kind of a joke).
Ophthalmology: In general this is a field that many physicians don't know a whole lot about and would likely do anyone well to have a basic understanding of how to approach the eye from an H&P stand point for the times that it may become relevant to psych whether it be drug side-effect or not missing Wilson's disease should you see it a couple times over a long career. Obviously 2-4 weeks rotating in the field won't make-or-break on that but the idea is getting exposed and developing generalized H&P skills, in addition to having at least a vague familiarity with ophthalmological issues.
Neurosurgery: Functional neurosurgery has occasionally been discussed, but its application to psychiatric disease (mainly OCD and depression) is rarely used (I think it was a Mayo publication I read that estimated the number of psychiatric surgeries performed in both the US and Canada combined was somewhere around 25/year). This rotation may be beneficial in getting a broader view of neurology and may pertain somewhat to CL psych. May be a good experience otherwise.
Anesthesiology: In any other setting than ECT I can't think of anesthesia being too relevant to psychiatric care other than what you may learn pertaining to things like critical care and some CL issues, but if you have any plans on being an ECT provider it would most certainly behoove you to be at least mildly familiar with some basic anesthesia.

Pediatrics

Pediatric Gastroenterology: After hearing a presentation on functional abdominal pain by a peds GI guy it seems as the overlap between psych and GI issues may be stronger in peds than adults. Seemed to me at least that a large portion of peds GI has psychiatric connections.
Adolescent Medicine: This is a population that often gets missed between peds and FM where you likely won't see much adolescents while doing peds. Many psychosocial issues in this age group ranging from sex to drugs to self-esteem.
Developmental-Behavioral Pediatrics: Seeing the treatment of many developmental and genetic conditions from a somewhat different approach. Could likely be helpful, even in the adult setting, in being more acquainted with recognizing genetic defects by physical appearance.
Pediatric Neurology: No explanation necessary.
Child Abuse Pediatrics: This has become an officially recognized fellowship and a number of peds programs are starting them up, though still somewhat of a small field. A number of them take medical students for rotations. Could be beneficial to child psych in being more attuned to recognizing some more subtle signs of abuse/neglect, but may also be beneficial to adult psych since you'd also learn more about the abusers.

Miscellaneous

Medical Toxicology: Relevant to both CL and emergency psychiatry with understanding and recognizing substance-induced mania/psychosis as well as seeing other aspects of dealing with ingestion suicide attempts.
Sleep Medicine: Developing the ability to naturally take a good sleep history, many sleep disorders being comorbid with psychiatric diagnoses, though technically a multi-disciplinary field that includes psych you may not get dedicated sleep time in residency unless used as elective.
Radiology/Neuroradiology: Doing a neuroradiology rotation may consist mostly of being more comfortable in understanding how MRIs and CTs are read and likely won't have a lot of direct benefit (for now) to the general psychiatrist, but the fact that they'll likely be some of the only images you'll order in your career as a psychiatrist it may be prudent to understand from the perspective of those you're consulting.
Geriatrics: Overmedication and medication side effects I would see as being the big learning piece of rotating through this field. I do, however, wonder if geriatric psych that you'll get in residency would cover most of the pertinent learning points that you may pick up on a general geriatrics rotation. I do know that some programs' geriatric psych rotation isn't really geriatrics (it is but it isn't, if you know what I mean).
Pain Medicine: This one may vary significantly by what the approach is (whether via anesthesia, PM&R, etc.) I would assume a psych pain doc may see more of the drug-seekers by virtue of it being less procedural than other specialties (just an assumption) but I'm sure this varies significantly from pain doc to pain doc.
Forensic Pathology: May be interesting in seeing everything else that goes into management of issues like suicide and getting an appreciation for however strong or weak the threshold of evidence is for determining cause of death.
Hospice/Palliative Care: CL relevant. Been mentioned by numerous medical students as being an aspect of medicine that is very beneficial that you otherwise won't get a lot of exposure to.

I'm welcome to any input. As I said, some of this may be way off-base. I'd appreciate solid contribution from anyone to alter, correct, enhance or change any of the objectives I have listed under any field. I hope this can be a better resource in the future than some of the sparse threads that need piecing together.

 

[nitemagi]

This is a good illustration of how mental illness exists in every medical specialty, and why psychiatrists should first be physicians. That being said, you only have so much free time in medical school, so pick the rotation that's interesting to you.

 

[st2205]

This is a good illustration of how mental illness exists in every medical specialty, and why psychiatrists should first be physicians. That being said, you only have so much free time in medical school, so pick the rotation that's interesting to you.

Precisely, which is why I hope this can be a resource for people to consider trying out fields that thu may have never though (or heard) of before. Also to give people options of rotations they may not want to do but may have a list of seemingly random rotations (i.e. surgical selective) that they have to choose that they may realize they can get something relevant out of it that they may have not previously thought. For instance, someone may be required to do a surgery selective and while not necessarily having an interest in urology could see its applicability to their future outpatient practice verse another month being pimped on general surgery.

 

[Daedra22]

Something that I've been interested in doing since before starting med school is an LGBT-focused elective. AMSA actually has a list of various rotations in this area, including primary care, endocrinology and surgery. I can't speak with authority since I don't start rotations until the fall, but it seems like these electives might be very helpful for future psychiatrists interested in LGBT health.

 

[Bartelby]

Mostly everything above can relate to psych, but it probably isn't crucial to take (for instance, I think you could do just fine without spending a month on optho or plastics).

As they relate to psych of that list I found neurology crucial, and medical toxicology extremely helpful. ER was very worthwhile.

 

[mkeguy]

i did ER and pain clinic and found them both useful for psych and medicine in general. i think ER should be a required course in med school, but thats just me.

 

[michaelrack]

Most surgical electives would be relatively low yield for a psychiatrist, especially if they are heavily inpt rotations. Rotations that I think would be helpful for a psychiatrist include neuro, endocrine, sleep medicine, outpt primary care, and medicine sub I. I would discourage GI unless it is a special area of interest; on a typical rotation you won't spend much time dealing with vague abdominal pain. I do strongly encourage an outpt primary care rotation.

 

[nitemagi]

Sleep medicine I found very useful when I was a med student (so I'll 2nd Dr. Rack's rec). I'd throw in pain as another good one, though recognizing you'll develop a different perspective as a psychiatrist.

 

[psychphan]

i did ER and pain clinic and found them both useful for psych and medicine in general. i think ER should be a required course in med school, but thats just me.

There are schools that don't require ER rotations?


As far as the original topic of this thread, I think the bottom line is, its pretty clear that psychiatry has a direct relation to (or at the very least psych issues can be found in) every medical specialty and sub specialty. I appreciate the list you made, but I question the utility, and certainly dont see the necessity of most of those rotations. Personally I believe a firm graps of medicine (achieved through inpt wards, outpt clinics, and ER) is the big necessity and think an extra month of one of those would have a much higher yield than Peds GI, any surgical rotation, and likely most medicine sub specialties. That being said though, most schools require plenty of months of those key med rotations, so if you are rounding out your final year of med school, I think you should look for rotations that you want to do because you are particularly interested in the field, or just plain think they are fun.
You can make a case for any rotation expanding your medical knowledge and making you a better psychiatrist, so why not do something that you find interesting?

 

[st2205]

I feel I must reiterate my intentions with my OP as I want to be clear on what exactly it is I'm saying. I'm not suggesting that any of these rotations are necessary for being a psychiatrist nor that they are guaranteed to produce the hypothetical objectives listed. I'm also not advocating that understanding and appreciating these issues could only be accomplished by doing a 2-4 week rotation in these fields. What I am doing, however, is trying to create a much more broad list of possibilities that 3rd and 4th year students may be able to perhaps hear about fields or rotations that they may have not previously understood that they had the option to get exposed to. Traditionally, the threads begin with the question of what to do other elective rotations in and the general concensus is that endocrine is good and the rest is "do what you think will be fun". This is true and I also advocate that what is fun and what may be beneficial need not be mutually exclusive. Also, I appreciate that most surgery rotations have little, if any, applicability to general psychiatry. Many schools (such as my own), however, require a surgical rotation in fourth year (or at least a second one during third year). Given that most people applying to psychiatry generally don't like surgery (I actually really enjoyed my general surgery rotation) they may have not be too excited and view it as another month that they have to simply 'survive'. To flip that around, it's good to be aware of all the possibilities within surgery so that someone doesn't just blindly end up on general surgery or some other equally 'miserable' rotation. For me, personally, I can't stand orthopedics and shan't be rotating in it. Nor do I want to spend another month just doing general surgery. Outside of that there are some decent opportunities for rotations that may fulfill that requirement that I may possibly a) enjoy or b) see some utility with regard to my medical career or c) both. I see a lot of my fellow medical students end up either rotating through the same rotations fourth year that they did third year or end up suffering through rotations they don't enjoy and don't take much from. In addition, it's also not uncommon to see people setting up 5 or so rotations in one field. All of this simply because people don't know, or don't investigate, all the options that are available to them. That's the idea. I'm required to do a peds rotation 4th year. I absolutely do not like general peds and I have absolutely no interest in child psych (as of now), so doing another general peds rotation (for me) would be terrible, but if I'm creative I can find a number of opportunities available to me if I take a different approach to it. I'm also not advocating that anyone will learn psychiatry from any of these rotations. More importantly I believe that what will best be learned is what is not psychiatry, so that when someone is dealing with nebulous somatic complaints they can have a greater fund of knowledge to draw from to recognize when something isn't psychosomatic, despite its vague presentation. Of course these skills ideally should be encompassed in a general medical education, but again much of medical education is what you make it -- and knowing your options and resources is most certainly a large part of that.

 

[whopper]

GI is very useful for you and them because several GI docs prescribe Pegasys (pegylated interferon) for the treatment of hepatitis C, and that in turn causes several people to become severely depressed. It's standard to do a Hamilton Depression Scale before treatment with that med. Most GI practices I've seen want a psychiatrist on board with them.

Irritable Bowel Syndrome is a disorder where psychiatry could lend some help to the GI docs.

Several psychotropic medication side effects are GI related.

 

[@JackShephard]

This has been a recurring thread each year and every time a few new thoughts are shared but I think it typically goes unanswered because of how many times it's been brought up over the years. A lot of the common rotations continue to get mentioned as being high yield and occasionally some pop up with an argument of why they think one particular rotation may be beneficial to do an elective in. I've tried to give pretty serious consideration to my fourth year schedule and tried to focus on the bigger picture of getting pretty broad exposure in medical school, so I'd like to share different things of what I considered in making decisions so that maybe it can help anyone give consideration to certain electives and possible objectives which they may have not thought about previously. This comes with a caveat that I'm currently a third year student (who obviously hasn't done any of these electives yet) and so my assumptions about some of these electives may be completely off-base, but alas random spattering of information I collect from others above me is the only thing I really have to go on.

On of the things I considered in exploring electives is that it is oft mentioned of being familiar with vague symptoms and complaints (an argument of why ER and primary care rotations are beneficial), which seems to make a decent amount of sense. In conjunction with this, because vague complaints have a large overlap with psychological interpretation and/or psychiatric manifestations, I would consider it imperative to be able to have a decent understanding of each organ system to evaluate, either by history or physical, whether something is more serious and needs workup/referral or if the symptoms are exacerbating by primary psychiatric diagnosis. The continuing theme from residents and attendings has been echoed about being a well-trained physician first. I think the goal with a lot of electives may not necessarily provide huge benefit in understanding that field per se, but developing, in general, stronger H&P skills in each particular area of medicine can help in being more attuned to observation (i.e. learning how to look at skin on derm and being more sensitive to seeing manifestations of abuse or from an ophthalmology rotation being able to more naturally look at someone's eyes and make quick judgements -- when evaluating a psychotic patient with Wilson's disease).

Between all the different subspecialties, settings and practice options in psychiatry the argument can likely be made for just about any rotation to be somewhat relevant. With that in mind, and with schools requiring selectives from specific areas, I've assembled this by larger encompassing fields to break it down by so that people may have a resource for understanding their options.

Quasi-mandatory (I'm not going to give explanations on why to do these as it should be rather obvious)

ICU
Neurology
Emergency medicine
Cardiology

Internal Medicine

Cardiology: See above.
Gastroenterology: Abdominal pain can be a rather nebulous symptom with many psychiatric connections, but an underlying GI pathology may or may not be present and would warrant competent skills on the part of the provider to understand when more evaluation may be necessary and also to reasonably exclude pathology.
Endocrinology: Aside from numerous endocrinological problems having psychiatric manifestations I believe having the time dedicated to focus in a bit on diabetes, which you will encounter daily, would be beneficial to understand much more than the routine approach of primary care.
Nephrology: Fluids and electrolytes important for any physician. Understanding F&E with mental status changes in a consult setting. HTN as well in a general sense. Also lithium nephropathy.
Infectious Disease: Pretty relevant for CL. Many infections causing encephalopathies, in addition to any other encephalitis, may be pretty important to know the big picture before you can step in as a consultant on such issues.
Heme/Onc:
Rheumatology: Fibromyalgia. Also exposure to SLE patients. Most certainly don't want to miss lupus when you see it.

Surgery

Urology: Incontinence, ED and other sexual dysfunctions. As an outpatient psychiatrist and especially a psychotherapist may encounter these issues frequently and could benefit from understanding the harder (no pun intended) diagnosis, management and treatment of both functional and pathological problems in urology.
Otolaryngology/ENT: May not have a whole lot of relevance, but tinnitus, vertigo and the approach to HA may be useful to know.
Plastic Surgery: Get to see histrionic PD -- not that you would do a rotation to do such or that you would really want to. Also, it will give you an opportunity to develop good aesthetical suturing so that when you're an intern and you stitch up that borderline that cut themself you can do such a wonderful job in minimizing scarring that the pt will not have as great an opportunity to use the scars for attention-seeking behavior (ok, this one's kind of a joke).
Ophthalmology: In general this is a field that many physicians don't know a whole lot about and would likely do anyone well to have a basic understanding of how to approach the eye from an H&P stand point for the times that it may become relevant to psych whether it be drug side-effect or not missing Wilson's disease should you see it a couple times over a long career. Obviously 2-4 weeks rotating in the field won't make-or-break on that but the idea is getting exposed and developing generalized H&P skills, in addition to having at least a vague familiarity with ophthalmological issues.
Neurosurgery: Functional neurosurgery has occasionally been discussed, but its application to psychiatric disease (mainly OCD and depression) is rarely used (I think it was a Mayo publication I read that estimated the number of psychiatric surgeries performed in both the US and Canada combined was somewhere around 25/year). This rotation may be beneficial in getting a broader view of neurology and may pertain somewhat to CL psych. May be a good experience otherwise.
Anesthesiology: In any other setting than ECT I can't think of anesthesia being too relevant to psychiatric care other than what you may learn pertaining to things like critical care and some CL issues, but if you have any plans on being an ECT provider it would most certainly behoove you to be at least mildly familiar with some basic anesthesia.

Pediatrics

Pediatric Gastroenterology: After hearing a presentation on functional abdominal pain by a peds GI guy it seems as the overlap between psych and GI issues may be stronger in peds than adults. Seemed to me at least that a large portion of peds GI has psychiatric connections.
Adolescent Medicine: This is a population that often gets missed between peds and FM where you likely won't see much adolescents while doing peds. Many psychosocial issues in this age group ranging from sex to drugs to self-esteem.
Developmental-Behavioral Pediatrics: Seeing the treatment of many developmental and genetic conditions from a somewhat different approach. Could likely be helpful, even in the adult setting, in being more acquainted with recognizing genetic defects by physical appearance.
Pediatric Neurology: No explanation necessary.
Child Abuse Pediatrics: This has become an officially recognized fellowship and a number of peds programs are starting them up, though still somewhat of a small field. A number of them take medical students for rotations. Could be beneficial to child psych in being more attuned to recognizing some more subtle signs of abuse/neglect, but may also be beneficial to adult psych since you'd also learn more about the abusers.

Miscellaneous

Medical Toxicology: Relevant to both CL and emergency psychiatry with understanding and recognizing substance-induced mania/psychosis as well as seeing other aspects of dealing with ingestion suicide attempts.
Sleep Medicine: Developing the ability to naturally take a good sleep history, many sleep disorders being comorbid with psychiatric diagnoses, though technically a multi-disciplinary field that includes psych you may not get dedicated sleep time in residency unless used as elective.
Radiology/Neuroradiology: Doing a neuroradiology rotation may consist mostly of being more comfortable in understanding how MRIs and CTs are read and likely won't have a lot of direct benefit (for now) to the general psychiatrist, but the fact that they'll likely be some of the only images you'll order in your career as a psychiatrist it may be prudent to understand from the perspective of those you're consulting.
Geriatrics: Overmedication and medication side effects I would see as being the big learning piece of rotating through this field. I do, however, wonder if geriatric psych that you'll get in residency would cover most of the pertinent learning points that you may pick up on a general geriatrics rotation. I do know that some programs' geriatric psych rotation isn't really geriatrics (it is but it isn't, if you know what I mean).
Pain Medicine: This one may vary significantly by what the approach is (whether via anesthesia, PM&R, etc.) I would assume a psych pain doc may see more of the drug-seekers by virtue of it being less procedural than other specialties (just an assumption) but I'm sure this varies significantly from pain doc to pain doc.
Forensic Pathology: May be interesting in seeing everything else that goes into management of issues like suicide and getting an appreciation for however strong or weak the threshold of evidence is for determining cause of death.
Hospice/Palliative Care: CL relevant. Been mentioned by numerous medical students as being an aspect of medicine that is very beneficial that you otherwise won't get a lot of exposure to.

I'm welcome to any input. As I said, some of this may be way off-base. I'd appreciate solid contribution from anyone to alter, correct, enhance or change any of the objectives I have listed under any field. I hope this can be a better resource in the future than some of the sparse threads that need piecing together.

This is a very detailed list.

I agree that anything can be related, but looking at a field like ENT - you mention:

tinnitus, vertigo and the approach to HA may be useful to know.

It seems like you can find a few useful things in any field but these complaints aren't necessarily bread and butter. I.e. I could do multiple weeks of ENT and only do surgery and advanced ENT topics, hardly ever coming into contact with these.

Excellent list though and thanks for the input.

 

[st2205]

This is a very detailed list.

I agree that anything can be related, but looking at a field like ENT - you mention:



It seems like you can find a few useful things in any field but these complaints aren't necessarily bread and butter. I.e. I could do multiple weeks of ENT and only do surgery and advanced ENT topics, hardly ever coming into contact with these.

Excellent list though and thanks for the input.

Someone posted a thread similar to this recently and I was in the middle of responding when I lost my post (that I was making from my phone), so I never finished it. Anyhow, I would revamp my list from this end of it now (as an intern who's now on psych after finishing all off-service months). Originally my intent was to highlight all the different possibilities of rotations available as I never had a specific list and thought one would be helpful just so I knew what was out there.

Anyhow, I'd say to do some things that are easy and fun and also do things that will make you feel more confident/competent in general as a physician and keep in mind you'll do (likely) 4 months of IM. On psych, I've been surprised (and occasionally pretty nervous) about the kinda of issues we're managing. I'm sure it's different depending on the facility, but being attached to the hospital we get about 90% of our patients from the ED and probably like 5% as transfers from medicine. They've been pretty sick. It was an unwelcomed surprise on my second day discharging a guy and being informed his BS was >500 only to find out he was admitted on SSI 1 and not his home U500 because it's not on our formulary. What a disaster. I couldn't get it much below 450 and eventually had to get a hold of his outpatient endocrinologist. Had another healthy guy come in in his 20s and ended up coding when I was on call. Lots of other things to that I never thought I'd see on the psych floor. Anyway, that's neither here nor there, but I recommend feeling comfortable enough to handle things enough to stabilize a patient until you can get them safely to where they belong, wherever that is.

I do strongly recommend neuro so you can learn more of the basics so in residency you can focus more on understanding it in a bit more relevant depth rather than still hitting some of the very simple things.

Of note, I spent my electives and fourth year doing: cardiology, toxicology, sleep medicine, nephrology, psych, GI, neuro, endocrine, ER, ICU, and clinical pharmacy (with a psych residency program for PharmDs).

Honestly, the one that I find the most useful for changing the way I currently do things was sleep medicine. Outside of that, it'd be between IM, FM and EM. Would have loved to have done a sexual disorders rotation with urology but wasn't able to work out.

 

[@JackShephard]

Thanks for the update. Great info

 

[masterofmonkeys]

st, this post was amazing. A few years too late for me, but still great stuff.

The one thing I didn't see here was 'I'm not going to do it but I like it.'

For me this was Cardiac Electrophysiology (yes I'm a geek)/CICU. As well as NeuroRadiology (Yeah there's some help there, but mostly it was a really cool attending and the physics is too awesome). If I didn't have spine trauma, I would've done some more surgical stuff as well.

Fourth Year is your last chance to play really, to get out there and have fun and see other things. I didn't even do a single month of psych my 4th year. And I don't regret that at all.

 

[IamPsychiatrist]

So, I'm looking to get more general medicine experience. I've done inpatient internal medicine and didn't like it very much.

Any thoughts on whether I should do a Sub-I in inpatient med or just basic family medicine if I would like to get more general medicine experience? I feel like the inpatient patients were super complex (5 chronic conditions @ once) and the family med patients were often too simple (cold, flu, back pain).

 

[IamPsychiatrist]

st, this post was amazing. A few years too late for me, but still great stuff.

The one thing I didn't see here was 'I'm not going to do it but I like it.'

For me this was Cardiac Electrophysiology (yes I'm a geek)/CICU. As well as NeuroRadiology (Yeah there's some help there, but mostly it was a really cool attending and the physics is too awesome). If I didn't have spine trauma, I would've done some more surgical stuff as well.

Fourth Year is your last chance to play really, to get out there and have fun and see other things. I didn't even do a single month of psych my 4th year. And I don't regret that at all.

Do you think I should focus on more internal medicine time if I feel like I could improve there or just do courses I find more fun?

 

[Nasrudin]

I agree with the "why not?" perspective to a certain extent. I mean, ortho rounds are a thing of beauty. I can play for team dork the rest of my life. But for 10 minutes of glory rounding on 10 patients. I get to feel like a stud. Groups of nurses get quiet and turn our way as we roll through like a fast breaking basketball team. Laughing at man jokes. Meant for men. Without the slightest self censure. Don't get me wrong dorks. I'm one of you. Just not right now. So don't talk to me. Or ruin this fantasy. I'll be back at your lunch table soon enough.

 

[IamPsychiatrist]

I agree with the "why not?" perspective to a certain extent. I mean, ortho rounds are a thing of beauty. I can play for team dork the rest of my life. But for 10 minutes of glory rounding on 10 patients. I get to feel like a stud. Groups of nurses get quiet and turn our way as we roll through like a fast breaking basketball team. Laughing at man jokes. Meant for men. Without the slightest self censure. Don't get me wrong dorks. I'm one of you. Just not right now. So don't talk to me. Or ruin this fantasy. I'll be back at your lunch table soon enough.

Getting cold feet?

Or just feeling the lure of money, power, prestige?

 

[Nasrudin]

Getting cold feet?

Or just feeling the lure of money, power, prestige?

No. Psych is where I belong. I just appreciate certain aspects of other medical cultures. And like or not there is a certain Breakfast Club motif running through the archetypes of different specialties. The same reason that analysts repulse me with their mental masturbatory acrobatics is the same one that attracts me to the pure, pragmatic, discrete manliness of ortho.

I'm joking. I would rather inhabit the creative nerdiness of psych culture. But in line with the thread topic it's fun to experience other stuff in light of how little 4th year matters in the first place beyond medicine. Of course, you can get valuable experiences from many fields as was so eloquently put above. But even when you can't there's something to get from it. In the case of ortho I derive a self-deprecating joke from it.

 

[st2205]

So, I'm looking to get more general medicine experience. I've done inpatient internal medicine and didn't like it very much.

Any thoughts on whether I should do a Sub-I in inpatient med or just basic family medicine if I would like to get more general medicine experience? I feel like the inpatient patients were super complex (5 chronic conditions @ once) and the family med patients were often too simple (cold, flu, back pain).

In short, they both suck. Do keep in mind that you'll get 4 months of some combo of them in residency. I'm not certain if more time on SubIs in them will yield much as you'll probably learn a lot more, at a lot faster pace, as a resident. Try to have fun, too. What else can you do a SubI in?

 

[IamPsychiatrist]

In short, they both suck. Do keep in mind that you'll get 4 months of some combo of them in residency. I'm not certain if more time on SubIs in them will yield much as you'll probably learn a lot more, at a lot faster pace, as a resident. Try to have fun, too. What else can you do a SubI in?

Oh, we have lots of options - could do psych, family med, or something random/fun/easy.

 

[masterofmonkeys]

You might consider doing inpatient internal medicine at a local private hospital if that can be arranged. Would likely be a more laid back experience and not as frenetic as a the typical teaching hospital. Then again, I think some others have already pointed out that you will get plenty of IM as a resident.

Nasrudin, I'm with you. Psych's where I belong, but I find other medical cultures intriguing.

Probably my biggest regrets of 4th year is that I didn't have the physical health to tolerate more surgical rotations, and that I didn't think to do more ER experience (for the Trauma experience).

 

[IamPsychiatrist]

Come on now guys, Ortho sucks.

It's only popular in America because we're obsessed about sports and they have a great lobby to pull in $$$$.

In any other country where ortho is paid the same as a general practioner, they get no respect and have little popularity.

It's the money and status, not the ortho.

 

[Nasrudin]

Look. If it was any kind of physical contest between us and them we would get murdered. Many of our sort would like to create an intellectual wall of condescension to compensate for this. Thinking themselves divorced of having testosterone producing organs. I prefer to laugh at it.

Secondly, I'm also referring to the intrinsic nature of their line of work. As a former tradesman I think working with your hands to build things is cool. The have a very focused discrete role that seems satisfying in its ability to be obvious in its improvement of patients' lives. Money and prestige differences are neither significant nor funny nor interesting enough to talk about.

Basically like the OP, I find beauty and value for us in all the fields. And like the masterofmonkeys I think our cultural differences are deeply funny.

 

[IamPsychiatrist]

Look. If it was any kind of physical contest between us and them we would get murdered. Many of our sort would like to create an intellectual wall of condescension to compensate for this. Thinking themselves divorced of having testosterone producing organs. I prefer to laugh at it.

Secondly, I'm also referring to the intrinsic nature of their line of work. As a former tradesman I think working with your hands to build things is cool. The have a very focused discrete role that seems satisfying in its ability to be obvious in its improvement of patients' lives. Money and prestige differences are neither significant nor funny nor interesting enough to talk about.

Basically like the OP, I find beauty and value for us in all the fields. And like the masterofmonkeys I think our cultural differences are deeply funny.

Oh, I don't disagree that each is interesting. I was more referring to your story of walking down the halls and being with the cool guys instead of dorks.

I'm a lot bigger and likely as strong as most of our ortho guys - so depends on the person. I could hold my own if we had a battle royal.🙂

 

[masterofmonkeys]

I think Nasrudin was being very tongue in cheek, a la the 1st season episode of Scrubs where JD gets to be 'cool' like the Surgeons during his surgery rotations and Turk has to hang out with the geeks.

The funniest thing that ever happened btwn me and an ortho was when he literally refused to believe I could be a psych resident (was seeing him for a shoulder issue). I'm a former light-heavy boxer and currently a very weak powerlifter/strongman competitor.

"Hey i know you, you're one of the new ortho interns."
"No, I'm a psych intern."
"Haha that's funny" <walks out of the room>
<comes back in> "You're gen surg right?"
"No, still psych."

Next appointment:
"Urology right?"
*facepalm* "Psych"
"Oh...you weren't joking."

 

[Nasrudin]

I think Nasrudin was being very tongue in cheek, a la the 1st season episode of Scrubs where JD gets to be 'cool' like the Surgeons during his surgery rotations and Turk has to hang out with the geeks.

The funniest thing that ever happened btwn me and an ortho was when he literally refused to believe I could be a psych resident (was seeing him for a shoulder issue). I'm a former light-heavy boxer and currently a very weak powerlifter/strongman competitor.

"Hey i know you, you're one of the new ortho interns."
"No, I'm a psych intern."
"Haha that's funny" <walks out of the room>
<comes back in> "You're gen surg right?"
"No, still psych."

Next appointment:
"Urology right?"
*facepalm* "Psych"
"Oh...you weren't joking."

Exactly. I love scrubs. And they made good use of these funny differences. I like to see more masculine males in our line of work, so I'm glad you guys are out there. But, trust me, I think it takes a deeper sort of guts to do what we do. I'm not at all trying to diminish us. I'm just musing over the differences in our group dynamics and how we roll. Which makes me laugh just saying it. Like I'm Napolean Dynamite's older brother, who somehow scores a hot black chick and is struggling for the words to brag about it. Something about that image is psychish and funny to me. Like that.

 

[Leo Aquarius]

I never saw orthopedic surgery as attractive. I almost feel like you give the underlings the task of fixing bones. Kings never get their hands dirty. They sit high in their chairs and listen, analyze, and speak.

 

[Nasrudin]

Fair point....and now back to our regularly scheduled programming! What electives to take and why....besides ortho...

 

[IamPsychiatrist]

I think Nasrudin was being very tongue in cheek, a la the 1st season episode of Scrubs where JD gets to be 'cool' like the Surgeons during his surgery rotations and Turk has to hang out with the geeks.

The funniest thing that ever happened btwn me and an ortho was when he literally refused to believe I could be a psych resident (was seeing him for a shoulder issue). I'm a former light-heavy boxer and currently a very weak powerlifter/strongman competitor.

"Hey i know you, you're one of the new ortho interns."
"No, I'm a psych intern."
"Haha that's funny" <walks out of the room>
<comes back in> "You're gen surg right?"
"No, still psych."

Next appointment:
"Urology right?"
*facepalm* "Psych"
"Oh...you weren't joking."

Representing psych the right way. I love it.👍

And btw, there are very few physician I know who could say they even tried to compete in strongman or powerlifting - so you're probably in the top few percent of physicians in that area.

 

[OldPsychDoc]

Representing psych the right way. I love it.👍

And btw, there are very few physician I know who could say they even tried to compete in strongman or powerlifting - so you're probably in the top few percent of physicians in that area.

What about Sixteen-ounce Bicep Curls?
I'm pretty competitive in that event.

 

[MacDonaldTriad]

I have two suggestions. Do anything but psychiatry. You will get enough of that soon.
Do Derm. That way you might know something when everyone starts showing you parts of their skin at family reunions.

 

[IamPsychiatrist]

What is better, inpatient or outpatient Neuro?

 

[OldPsychDoc]

What is better, inpatient or outpatient Neuro?

Which ever one has you doing more hands-on neuro exams.

 

[IamPsychiatrist]

Which ever one has you doing more hands-on neuro exams.

I've yet to do Neuro, so I don't know.

From my IM experience I would guess Outpatient. Sometimes academic center inpatient becomes a huge rounding session with less physical exams.

 

[OldPsychDoc]

I've yet to do Neuro, so I don't know.

From my IM experience I would guess Outpatient. Sometimes academic center inpatient becomes a huge rounding session with less physical exams.

That was my experience on inpatient neuro as well--a few zebras, but mostly "Stroke--place feeding tube, refer to rehab..."
Outpatient was 5-6 full exams a day with significant findings, a few interesting consults, and relevant management issues--seizure, migraine, MS...
YMMV

 

[hamstergang]

I've yet to do Neuro, so I don't know.

Well it depends on where you do it, so we won't know the answer. Ask other people at your med school.

 

[Shikima]

That was my experience on inpatient neuro as well--a few zebras, but mostly "Stroke--place feeding tube, refer to rehab..."
Outpatient was 5-6 full exams a day with significant findings, a few interesting consults, and relevant management issues--seizure, migraine, MS...
YMMV

Similar experience. Try to do outpt neuro... it'll serve you well in the long run.

 

[Fabio001]

I need some sincere advice in planning for my fourth year. At my school there is required clerkships in ICU, neuro, an AI (psych not accepted), emergency, and teaching (one month in the Sim Center teaching younger students). Each of these is a month long. This leaves only 16 weeks of elective time of which 4 can be used for board study, so really only 12. I am currently scheduled for 2 of child/adolescent psych, 2 of anesthesia, 2 of cardiology, 2 of med tox, and 4 of pain management. What do you guys think?

I was confronted by one of the deans who felt that I would potentially be hurting myself by not doing more psych, particularly at the beginning of the school year. I can't do c&a before early November for various reasons (not gonna be able to get a letter 🙁 ).

 

[Shikima]

Try to get as much medicine experience as you can before getting into your internship. The psych will develop, but only devote 1 block to psych at the end just before graduation.

 

[notdeadyet]

Agree with the comments above. At most places, inpatient neurology is inpatient medicine patients whose chief complaints happens to be neurological. They tend to come diagnosed and with a fairly rote treatment plan. Working up someone who comes into your office with weird tingling, pain, or cognitive impairment is much more interesting and relevant to the work you'll do as a psychiatrist, regardless of setting.

 

[Fabio001]

Agree with the comments above. At most places, inpatient neurology is inpatient medicine patients whose chief complaints happens to be neurological. They tend to come diagnosed and with a fairly rote treatment plan. Working up someone who comes into your office with weird tingling, pain, or cognitive impairment is much more interesting and relevant to the work you'll do as a psychiatrist, regardless of setting.

So what are you suggesting exactly? Substitute a pain management spot for some outpatient neurology?

 

[Psychotic]

I need some sincere advice in planning for my fourth year. At my school there is required clerkships in ICU, neuro, an AI (psych not accepted), emergency, and teaching (one month in the Sim Center teaching younger students). Each of these is a month long. This leaves only 16 weeks of elective time of which 4 can be used for board study, so really only 12. I am currently scheduled for 2 of child/adolescent psych, 2 of anesthesia, 2 of cardiology, 2 of med tox, and 4 of pain management. What do you guys think?

I was confronted by one of the deans who felt that I would potentially be hurting myself by not doing more psych, particularly at the beginning of the school year. I can't do c&a before early November for various reasons (not gonna be able to get a letter 🙁 ).

How much time do you get for vacation/interviews? By my quick count it doesn't look like any...unless you will be in school through May? Or do you have to work interviews in during rotations and electives? I could have never interviewed at the far flung places I went except during dedicated time (2 months).

You don't need more psych UNLESS you don't have at least one strong letter from a psych attending from your clerkship (some programs want a letter from the psych director, too).

 

[Fabio001]

How much time do you get for vacation/interviews? By my quick count it doesn't look like any...unless you will be in school through May? Or do you have to work interviews in during rotations and electives?

We get two 2 week blocks for interviews and a month off at any time we choose. Our final clerkship ends in the middle of May.

I have a couple strong letters, but I did my clerkship at the county outpatient clinic so neither letter writer has "professor" written after their name. Is that a problem?

 

[Fabio001]

On that same note my entire psych experience thus far has been outpatient with only three days of c/l and a few call shifts of psych ED

 

[Psychotic]

We get two 2 week blocks for interviews and a month off at any time we choose. Our final clerkship ends in the middle of May.

I have a couple strong letters, but I did my clerkship at the county outpatient clinic so neither letter writer has "professor" written after their name. Is that a problem?

Letters should come from attendings, not residents. Lack of professor title probably matters less, but I am not sure. Certainly not an ideal situation.

I recommend you request an additional letter from the Psych Dept Chair as your 4th letter (as for your 3 basic letters, in addition to the psych attending I also recommend an IM and perhaps an FM or similar outpatient letter, attendings with professor status preferred) - the Psych Dept Chair will want to meet you, discuss it, etc. Ask for that letter in June, send him your CV, list of programs you are applying to, etc...they expect these requests, knowing that some programs require it. Maybe you include at least one program on your list that requires this letter? In case the question is asked?

 

[Psychotic]

.

 

[Fabio001]

The psych rotation sites at my school were variable. Nobody was happy on the inpatient unit, but they got to leave around noon each day which they liked. The state hospital across the street was similar. C/L was the only place where the 3rd years did a lot of notes. I felt lucky I got to go to the county as I had a lot of time to get to know the attendings, ask questions, and see a large amount of patients with pretty good variety. I also got to spend a day at the county jail and a couple mornings in court. Maybe my clerkship experience was weak, but I wouldn't know that as it's the only one I've done.

I have done research in psychiatry if that counts for anything?

 

[OldPsychDoc]

I need some sincere advice in planning for my fourth year. At my school there is required clerkships in ICU, neuro, an AI (psych not accepted), emergency, and teaching (one month in the Sim Center teaching younger students). Each of these is a month long. This leaves only 16 weeks of elective time of which 4 can be used for board study, so really only 12. I am currently scheduled for 2 of child/adolescent psych, 2 of anesthesia, 2 of cardiology, 2 of med tox, and 4 of pain management. What do you guys think?

I was confronted by one of the deans who felt that I would potentially be hurting myself by not doing more psych, particularly at the beginning of the school year. I can't do c&a before early November for various reasons (not gonna be able to get a letter 🙁 ).

An elective in psych can help you have a paper trail that demonstrates that you really are interested in psych, and help broaden your base in psych a little (e.g. doing some child when you wouldn't otherwise get that exposure). But beyond that, as others have said, take the time to do the "other stuff" that you might not get a chance to do again. What you have looks decent.