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Not sure if I should continue in psychiatry

Discussion in 'Psychiatry' started by omgwhy, May 26, 2017.

  1. omgwhy


    May 26, 2017
    Hi, I'm a resident in psychiatry. The more time goes on the more I feel I can't stand this field. I am miserable whenever I am on psychiatry and was happier when I was off service as an intern. I'm not sure if this has to do with psychiatry itself or my program. In medical school, I did four month long psychiatry rotations and I enjoyed them very much. I found the patients and the material interesting. I got residency interviews at many good programs but unfortunately matched somewhat low on my list but not at the bottom of it. I was still okay with the program I got.

    After arriving at my program, I found that many of the things that made me rank this program higher than others were lies or exaggerations. While the department here technically has a fellowship in the sub-specialty I want to go into, it is a joke. There's only one guy working in the sub-specialty and he makes up the entire program for it. The subspecialty is not even his main area of expertise and he makes no money with the subspecialty even though I know it's a very lucrative subspecialty in other places. There is literally one clinical site that is truly specific to the sub-specialty. I was told I could do an elective in the subspecialty as a second year but this elective does not actually exist.

    The attendings here are sparsely involved in clinical care. They are not present most of the time and teaching and supervision are limited. We basically have to teach ourselves psychiatry on top of our well above average work load. We spend most of our time with the resident to attending ratio being 5:1 and the learning to scutwork ratio is worse than that. My friends at other programs have lots of 1:1 attending interaction. In third year (outpatient), there is no direct supervision for most of the patients though I was told there would be. There is limited structure on our psych services. It's unclear what each person's role is on a team. No one explains anything to the interns because everyone assumes someone else has told them and/or they already know even when logistics are not intuitive. I did not find out our psych unit had a padded isolation room until 9 months into intern year despite spending plenty of time on the unit before that. I still constantly hear about supposed departmental policies that I "should" have already known about. We were not given any sort of handbook or formal instruction on these policies. I spend all my time writing notes and doing social work and case management. The admin at our program is not receptive to feedback and any complaint a resident has is always dismissed with the excuse being that the complaint is due to something being wrong with said resident, even if all the residents feel that way. We are treated like delinquent children instead of adult professionals. We have no contingency plan for if someone is sick so everyone involved just gets screwed. Every other department here has a contingency plan. The other residents in my program don't seem to give a crap that our training is not ideal. They just want to get out of work as quickly as possible and then get wasted like college kids on the weekend. I have tried to work on improving things here but no one else will engage in it.

    Furthermore, I hate spending so long talking to patients who aren't engaged in their care and don't respect me. I hate delving into the minute details of people's social history so I can better handle their dispo. I hate all the freaking talking about nonsense and listening to patients' endless rants about non-pertinent information. I hate typing notes that are 5 times longer than the other services. Why are the notes so freaking long? None of this crap was a part of the psych rotations I did in medical school.

    Off service, team member roles are better defined. There's more teaching. There's less social work. I spend my time figuring out medical problems and treatment plans instead of dispo crap. I like being able to order labs, use evidence from physical exams to make decisions, and practice evidence based medicine instead of just arbitrarily prescribing whatever attending's pet drug for no apparent reason. Should I switch specialties? Am I a bad match for my program? Am I just burned out? Am I a whiny delinquent child? Sometimes I think I would like to quit medicine altogether but I feel that I can't with all this debt. And sometimes I am very happy about being a doctor (usually when I have been off service).

    Things are complicated because I have no personal life here and no time to develop one. Long distance has destroyed the relationship I came into residency with. I'm single in a city full of young families and college kids. Dating for people my age seems to be non-existent and I don't have time for it anyway. I'm far away from my family and friends from my previous life. I tried to transfer programs this year but it didn't work out due to funding problems even though a program near my hometown really wanted to take me. I don't know what to do. My mood has been okay until this past week when I've noticed it's declining slightly as I'm back on my least favorite service. I don't have neuro-vegetative symptoms. I'm not anxious. I don't think I am mentally ill, but I am not happy with my life right now, as my life is this residency that I am dissatisfied with. I would be happy for any advice or constructive comments.

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  3. TexasPhysician

    TexasPhysician Moderator Physician 7+ Year Member

    Sep 1, 2008
    I assume you are an intern?

    PGY1 is rough at many programs. Inpatient psych is certainly not my preference either. Patients there have a poor prognosis which is discouraging.

    Maybe your training will improve each year, but maybe you are dealt a bad hand?

    Residency training doesn't take kindly to transfers. It is quite difficult to transfer within or out of a field to a better program. It often requires a lot of luck.

    On the plus side, you are about 1/4 done with residency, and if you want to transfer out after pgy3 for child, you are 1/3 done with your program. Study on your own, attend some good conferences, and build a social group. Surviving another few years opens endless possibilities to your future.
  4. omgwhy


    May 26, 2017
    I am an intern, indeed. Thanks for being encouraging. I have thought about a switch to neuro since it's seems more objective and less bull****ty. Another thing that bothers me about psych is people pretentiously trying to psychoanalyze each other all the time. Please.
  5. Armadillos

    Armadillos 5+ Year Member

    Feb 5, 2013
    If your truly only getting 5:1 supervision and nobody is teaching you or caring about your performance, then why are you compelled to write unnecessarily long notes or practice in other ways you don't like? If nobody is going to notice can't you just practice however you want?
    wannabie and GUH like this.
  6. FlowRate

    FlowRate Physician 7+ Year Member

    Oct 13, 2008
    I could imagine the answer has something to do with billing and case management hounding the residents to do really excessive documentation. The attendings may have nothing to do with it.
    MedMan80 and GUH like this.
  7. omgwhy


    May 26, 2017
    Yeah,our templates are created such that there are spaces for all the required different parts. And there are a lot of required parts. I have not counted but I'd guess there are at least 75 fields to fill in if not more. If we don't do it we here about it from billing or someone else. The upper level residents encourage us to write a lot for whatever reason. They sometimes say it's to cover yourself if there's a lawsuit. Sometimes the chief will send out an email insinuating we're lazy for not putting more into the notes. I'm not sure who or what motivates him to do that.

    And it takes a fraction of the time to tell a resident what the plan should be compared to what it'd take to explain why that should be the plan.
  8. ExcaliburPrime1

    ExcaliburPrime1 2+ Year Member

    Sep 17, 2015
    I sympathize a lot with what you wrote as I am also a PGY-1 nearing the end of first year. The first paragraph in particular I feel is a sense of disappointment at the disconnect between your experience of psychiatry in your medical school program vs. that at your residency, combined with a feeling of being "duped" in some ways about the program. I often feel the same way and your post quite articulately put many of my concerns (at least the ones in the first paragraph) on paper.

    My advice is to hang in there. There's no guarantee that you will be happier at a different program and it would take significant effort to extricate yourself at this point. You can try to make things better (for instance, maybe start a handbook or at least just down some key pieces of information on how your unit functions on a couple of sheets of paper, which will be treasured and perhaps added to by future interns!) Admittedly, it's hard to embark on something positive like that when you are so demoralized. The other option is to keep your head down, do the minimum needed for your program (and your conscience) and just focusing on the bottom line for your patients (no one else is thinking about their welfare!) and persevering until you're done with training. Thereafter, you have a lot of flexibility as an attending to accept the kind of job you want where you can help your patients and yourself in a reasonable way, paying off your loans, and making some money.
  9. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    And that won't even save them from the insurers because the documentation provided doesn't contain the necessary material to keep them in the hospital.
  10. chicagochildpsych

    chicagochildpsych 2+ Year Member

    Jan 11, 2015
    Residency sucks at most places, especially for an intern far from a support network. This is temporary, and you will get your life back. Finding a therapist (in no way affiliated with your program) may help. Hang in there.

    Sent from my iPhone using SDN mobile app
    wannabie likes this.
  11. TexasPhysician

    TexasPhysician Moderator Physician 7+ Year Member

    Sep 1, 2008
    These are potential faults with your program, not psychiatry.

    At my training facility, Neuro had poor training, overworked residents, and had a rough reputation. I learned on my Neuro rotation to keep my mouth shut as my diagnosis and management skills in 2 weeks were too often better than the chief's. This wasn't boding well for my work schedule determined by the chief. I'm not bragging as some medical students on rotation were also better prepared.

    I do not refer patients to anyone in Neuro graduating my program after witnessing their lack of expertise.

    If you want to transfer, be sure it is into a good program, and do so by July. After pgy2, there will be a funding problem that makes it close to impossible. Otherwise, instead of dwelling on the faults, train yourself to be better, and find ways to simplify the scut work.
  12. Psychotic

    Psychotic 2+ Year Member

    Sep 17, 2013
    where the sun do shine
    When you say "lies and exaggerations," are you saying you felt the program misrepresented itself? Or did you fail to do your homework?

    I realize you don't want to reveal the program (unless you do), but you could do others a service here by giving more information - what did you miss about the program from interviewing and doing research on it? What is the reputation of the program here on SDN? Are your fellow co-residents feeling the same as you? Etc.
  13. NickNaylor

    NickNaylor Thank You for Smoking Physician Lifetime Donor Classifieds Approved 7+ Year Member

    May 22, 2008
    Deep in the heart of Texas
    With respect to the issues related to your program (rather than your misgivings about inpatient psychiatry), have you talked to anyone about them? Is your program leadership aware of these things? Is your program leadership willing to accept feedback? Nothing is going to change if the program isn't aware of the issues... it probably won't change for you, but perhaps, for example, they could help set you up with alternative electives at sites that might provide you with the clinical experiences you're looking for in whatever subspecialty you're talking about.

    Your program may just ignore you and do nothing, but at the very least I think it's a reasonable idea to mention some of these things in a tactful and non-confrontational way and see what happens. Better than transferring/sucking it up and being unhappy with your training/most other possibilities.
  14. thoffen

    thoffen Member 10+ Year Member

    Aug 14, 2006
    If you can find a mentor (senior resident or faculty member) that is not judgmental of your experience, then it will do you wonders. It's hard for us to know externally the validity of your concerns or the options you have if you desire a change.

    Generally speaking, it seems your concerns are a blend of program specific problems, system related issues, and narrow clinical experience. I have a hard time believing, if someone ever had genuine interest in the minds of people, that there is not a niche in psychiatry that would be very fulfilling. Getting there is another story.
  15. omgwhy


    May 26, 2017
    I mean that I was told things there were not true, as were other people from my medical school who interviewed at this program. I have even spoken to one of the residents that knowingly told my friend from med school inaccurate things and said resident agreed that he had been misleading as he felt uncomfortable being honest in the situation at hand. I extensively reviewed all the information that was available about the program, including SDN reviews from the past 5 years, the program's website, and my interview day notes and materials. I will say this program's interview day materials were low on information compared to most places I interviewed. I was in communication with multiple people at the program following my interview to get more information. Perhaps differences in my experience here and those of some of the upper levels I spoke with prior to making my match list are due to changes in the program's first two years that they may not have been aware of. Perhaps some people I interviewed with spoke to things they did not have full knowledge of and that's why I was misinformed. One person I interviewed with is no longer with the program because of behavior issues, along they were perfectly pleasant and charming during my interview.

    My co-interns share many of my concerns but I admit they are not as unhappy as I am. Perhaps because they aren't as socially isolated (have spouses or other family and friends here or nearby) or because they desired this program/location more coming in. Or they just aren't sharing something that personal.

    I have tried to make changes as much as I can with some success. I made sure I was honest with interviewees this year. I have attempted to speak with admin and faculty about areas I think need improvement but they are intermittently receptive at best. I think this is partly because everyone is somewhat overwhelmed by their workload all the way to the top. there are also culture issues. Response to feedback is often along the lines of what I mentioned in my original post. I've witnessed others attempt to voice concerns only to be criticized as lazy, whiny, or inadequately dedicated to learning.

    I don't want to reveal the program as that would make my identity obvious. I'll attempt to find some other way to spread information at another time.
  16. omgwhy


    May 26, 2017
    That's what I'm worried about.

    Overall, everyone here has been very encouraging and I feel a bit better after reading your responses. I'll keep trying to make this work... and I'll just plan to practice in a different setting as an attending
  17. tr

    tr inert protoplasm Physician PhD Faculty 10+ Year Member

    Nov 17, 1999
    I'll be the odd one out and say you should try again to transfer out. That sounds like a bad program and four years is a long time to be miserable, plus from what you are saying it sounds like you may end up with not-very-good training, which will be a long-term detriment to your professional life.

    Usually transferring into PGY-2 at a different program is doable, why didn't it work out with the one in your hometown? Could you try again to enter that program as a 2?
  18. tyrionlannister00


    Jul 10, 2016
    West Coast
    Dude, are you describing my program!!? LOL... the one thing I would say, is look at the upside... when you finally get to work for your money, no your notes will not be long, they will short and you won't have to talk to an attending, you will be your own boss... psych is easy as pie... I'd stick it through, talk to some psychiatrists on the other side and not in your program, that's where I found my happiness... knowing what the future holds.
    Last edited: Oct 27, 2017
  19. FlowRate

    FlowRate Physician 7+ Year Member

    Oct 13, 2008
    Unless case management is hinting at the criteria they need to justify continued hospitalization.
  20. Shikima

    Shikima Physician 10+ Year Member

    Oct 15, 2006
    UM doesn't do a good job in guiding attendings or residents in meeting continued stay criteria.
  21. You mention well above average work load, would you cite an example?

    Also you don't have to name your residency but I'm pretty curious. At least share the region? North, southeast, west etc
  22. omgwhy


    May 26, 2017
    Here's the longer version of what happened with that program. I interviewed there. They said they wanted to take me but it had to be approved by the institution's education committee. That committee did approve my transfer but then there was another committee than the PD wasn't aware of, a finance committee. That committee felt that taking on an additional resident was not an option financially at that time.

    I missed my chance at a lot of the programs that offer PGY2 spots every year because my PD dragged their feet sending out their letter supporting my app. I had everything else ready, including other new letters of rec but programs would not serisouly consider me without the PD letter. By the time it got sent it out, they'd already sent out their interview invites. And yes, I repeatedly prompted my PD to send it over the 4+ weeks I was waiting for it. I was considered for other spots later on and was close for some but in the end I just kept hearing "it was an unusually competitive year with a higher number of applications than usual."

    Regarding the above average work load... not sure why examples are necessary... but my psych work week is most often 70-75+ hours which is more than any of my friends at other programs and more than I heard mentioned by residents at my other interviews. I have violated duty hours repeatedly on psych. I have fewer "golden weekends" than my colleagues here in internal medicine. No one covers for us when we go to didactics (despite them being advertised as protected) so pagers are constantly going off during our limited teaching sessions and we often end up with less than 25% attendance by the end as people have been pulled away it couldn't come in the first place. As mentioned in third year we see twice as many patients per day as residents at most other programs and the total number of patients we follow is higher. I do not have exact figures but no one here (residents, faculty, admin) disputes that this is the case. I'd be fine working more if I felt like I was learning psych well but I don't. I more seem to be learning how to get non-patient care tasks and documentation completed quickly.

    I am not the only person here who is unhappy. I know several people have had mood and anxiety issues for the first time in their lives since coming here.

    Anyway... I didn't originally post here because I wanted to prove that things are terrible. I know they could be worse. I have tried to make the best of it but I know myself and if I had known what this program is really like I would have known I would not be happy here. People who are interviewing should not be afraid to ask for specific details and keep pushing if they aren't readily provided or just steer clear of gamey programs altogether. This place was great at making itself look good but the reality doesn't measure up.

    I'm still confused about whether psychiatry is right for me although I was dead certain when I arrived here. I'm not sure what to think as there's no way I could continue like this for 20 more years. The areas that used to interest me just make me angry when I think of them now... partly because I know I won't get good experience with them during residency. As a result I worry that I will be stuck continuing to work in the sort of environment I've found at my program. I hope this is not the case. I'm going to stop posting in this thread now as dwelling on all this is not helping me. Ill make a final attempt to get out of here but then I'll go back to trying grind through this and get what I can out of it.

    Thanks everyone for the encouragement
  23. 70 hours a week on psychiatry rotations? Holy crap. I don't even know how you would have time to do outside reading. Sorry, it seems like your program isnt supportive of the education aspect of residency. I hope things get better for you.
    Last edited by a moderator: May 31, 2017
  24. rlx009


    Jun 22, 2016
    Hi omgwhy, your post hits close to home, and all your points are completely valid. I completed my second year in psychiatry and bounced to transfer last year, and unfortunately am still waiting to get a spot. I found a good place a few months ago but they had funding issues. I tried to bounce my 1st year a few months in and the PD was not happy, which got me labelled as a black sheep even though I was top of my intern class for most everything. I thought about transferring to neuro but they were completely overworked and I didn't want to do neuro exams for the rest of my life. I was alone, away from my family and friends, in a very foreign place from where I grew up. It's alienating, frustrating, and everything makes you irritable, I get it.

    To address some of your concerns. Regarding note writing, yes, it's gonna be a lot, a lot more than any other specialty, and that's what separates us from say 2 liner neurosurg notes. History taking is longer and much more thorough, and yes it's annoying, but in psych, history is EVERYTHING. You'll pick up a lot that way, and only then can you truly help. Drunk idiot coming in at 1AM sat morn is gonna annoy you, but it's still a cry for help, and the way I look at it, we're the fork in the road. We have to be the person who says hey, enough, let's get you better. It's time consuming but the way I look at we have 4 short years to learn a lot.

    Attendings and other residents psychoanalyzing is annoying, but often it's so instinctual they can't help it. Don't take it personally. DO NOT try to change the program. I should have taken all my friends' similar advice: keep your head down and get by. I shook the tree a bit much on top of being a black sheep, and got myself into more trouble than I wanted to be in. Self learning is your best friend in residency. They'll do the bare minimum to meet ACGME standards. Pick up a few books and teach yourself, you'll easily set yourself apart from the rest, and prepare yourself for future success. Message me and I can send you a list that helped me. Attach yourself to attendings that care and want to teach, even veteran nurses. There are people who care, just seek them out and learn from them.

    I hated being on non-psych rotations because of how condescending they all were, it really got to me, and I tried to find refuge in the psych department but with all the psychoanalyzing and nonsense infighting it wasn't good there either. You'll have to find (I hate to say it) good coping skills, apart from drinking and video games. I hope your second year gets better, even though it'll be more work. Hit me up if you have any more qs.
    Sunny in Psych and Crayola227 like this.
  25. MedMan80


    May 23, 2017
    Hope things are okay with OP, just wanted to share my first experience of PGY-1. I remember first day on the inpatient unit there was so much subjectivity in our notes and documentation. CM would hound us and taught us "note grooming", to justify continued hospitalization, transfer to higher level of care (LTC psych hospital). It was shocking to me that we weren't documenting exactly what we were seeing (contrast to medicine). To the OP all i can say is that it does get better, once you are licensed you practice the way you want to, there's alot of treatable mental illness out there and being a great psychiatrist you CAN make an impact!
  26. FlowRate

    FlowRate Physician 7+ Year Member

    Oct 13, 2008
    I think there's a continuum here. On one end, you fabricate/exaggerate to justify high/higher LOC. On the other end, you omit/understate either out of laziness or to justify discharging to lower LOC. Both are unethical. But between those two extremes, there's documenting your thinking in a way that emphasizes the aspects of the case that justify your plan of care without exaggerating, fabricating, omitting, or understating information. You really should be documenting what you're seeing.
    Erratafromthetext likes this.
  27. Sunny in Psych

    Sunny in Psych Banned Banned Account on Hold

    Dec 12, 2017
    I am not a psychiatrist, but a PMHNP with 14 years experience. I read your post with both interest and admiration for such insightfulness. It sounds like you will do fine once out of this less than ideal residency. No, our notes are not always 10 pages long once out doing things your way, depends. You guide patient talk and redirect, as you don't have time for minute details and must keep the conversation on task. I went through a vigorous program with exceptional psychiatrists as mentors. That is important. It's not just the text book information, but the soft signs and intuition that guide your evaluations. I'm sorry to hear that you are not obtaining the guidance and support you had hoped for. Perhaps you can change to a better residency. In the long run, you are the type of person who SHOULD be in psychiatry, not those trying to squeeze by and party every moment they can. I think we all second guess as we go along, but it will be more fulfilling in the future.
    Last edited: Dec 15, 2017

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