PGY-3 is not the land of milk and honey I was promised

[Ludwig2000]

Alright, maybe it wasn’t exactly promised. But there is a definite, pervading narrative at my program that PGY-2 is the bad year. You just gotta get through PGY-2. “Only a month left of PGY-2! Dude you’re almost there!!” And on and on.

And in terms of hours spent at work, PGY-2 is our worst. BUT!
I’m finding myself utterly drained by 4-5pm, pretty much every week day so far this year. So much so that I’m wondering if there’s something going on with me.

Short of some kind of organic thing, differential diagnosis for my mental state includes:
(1) cumulative effect of meaningless and ineffectual bureaucratic tasks. Getting set up in a new system (outpatient sites), x y and z things don’t work on first try, have to re contact the various and amorphous administrative people or IT that sent/set up each thing to say it’s still not working. Hopefully decreases over time?

(2) outpatient population enriched for people who don’t have major mental illnesses so much as problems with living in post industrial society with bad economy, where even if they do have a job it’s for positions like the people I’m having to contact in (1). End up listening to a fair amount of venting, feels like little is going to change.

(3) Mismatch in expectations. In PGY-2 I was working hard, but this was very much expected given the narrative at this program. In PGY-3 I guess I thought… I’d be getting to do whatever I wanted? I don’t know what I expected, obviously it’s still residency, but I guess I at least expected to enjoy it more than PGY-2 and I’m actually enjoying it less.

(4) Too many different supervisors, all assigned to me without my input. The total amount of time in supervision meetings feels like a lot, and yet somehow I think I’d prefer it all be with one supervisor even if the same total time. Even better, one that I’d pick based on well-matching styles. Obviously there are pro’s to the variety, but in keeping with a recent Office Space reference on this forum, I feel like I have 8 different bosses. 8? 8, Bob.

(5) maybe I like inpatient, not outpatient? I do think even in med school I found “clinic days” (FM, OB/Peds clinic, etc) more draining than inpatient. Maybe the “flow” of slotted appointments just doesn’t sit right with me, compared to the flow of rounding and then budgeting time as appropriate to tasks.

(6) [wild card] COVID fatigue? Man am I sick wearing masks and all this.

That’s probably all I got.
We’ll see if this is all just an extended transition to a different environment and I’ll be back to my usual chipper self soon. But I’d be interested in hearing from others who feel or have felt similarly. I suppose also this may temper expectations of any younger residents who are also eagerly awaiting this sweet, sweet outpatient time. That’s not to say dread it, young grasshoppers, but be realistic.

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[Crayola227]

I just came here to share my lol at the thread title.

 

[shoomer]

Fellow PGY3 here and I feel very similar, I basically agree with every single one of your points. I had some easier days as things were initially getting set up and even those were less enjoyable than my typical busy PGY2 day.

I think point 5 is the key here, I'm also wondering if outpatient is just not my cup of tea. A large part of it is definitely worsened by residency (needing supervision, no control over your schedule, no control over your patient population) but the fundamental aspect of having scheduled appointments all day with "soft" diagnoses/"worried well" patients almost fills me with a sense of dread.

I also am so accustomed to a frequently shifting schedule with rotation blocks and a constant change of pace that an entire year in this setting is almost daunting. I haven't been in a static environment like this since preclinical years of med school.

 

[Celexa]

Pgy3 was harder than pgy2 for me. The learning curve in transitioning to outpatient is steep and you no longer can look forward a few weeks to doing something different.

Got a lot easier in the second half of the year, though.

 

[TheRightMedication]

Helping people see thier problems in living more clearly is a big part of outpatient psychiatry. Once you get better at psychotherapy and helping people in ways other than medications, you might feel more mastery and like it better.

 

[adiradirim]

Starting off in outpatient is hardest for about the first year as you're establishing patients. For the first while, every single patient is new to you so you're working hard. Once the followups build up, it gets easier as you know the patients. At least this is true for me.

 

[samac]

Starting PGY 3 has been soul sucking for me and has only solidified I am an inpatient psychiatrist.
The every 30 minute grind is sooooo exhausting.

 

[Ludwig2000]

Starting PGY 3 has been soul sucking for me and has only solidified I am an inpatient psychiatrist.
The every 30 minute grind is sooooo exhausting.

“Soul sucking” was actually the exact term I was thinking earlier today, while driving to clinic

 

[PikminOC]

No control over your schedule, no control over your patient population) .... In corporate medicine you will have this as an attending

 

[ObsequiousAplomb]

The transition to outpatient is much bigger than the transition among all the inpatient rotations. At the end of the day, VA vs academic vs private for-profit vs community vs CL vs ER vs Acute detox vs state hospital is all still inpatient. It's still mostly over-emphasizing the medications and over-emphasizing the benefits of short-term measures. You're managing the SW, RN, techs, and their expectations. Slight management of patients.

Outpatient is a huge difference from all that. You're usually one-on-one with just the patients. Minimal meetings with ancillary staff. Instead you spend all those hours in psychotherapy supervision and so now you're managing your supervisors and their expectations a great deal. Because it's more therapy, which you haven't done much of yet, it will feel like you're doing everything wrong at first, no matter how well you are doing it.

Actually explaining the risks, benefits, and alternatives to patients and all that is at first really exhausting. Even people who love outpatient usually find the first month tiring. I know I did.

It gets easier, whether you end up liking outpatient or not. You'll get a hang of the new setup, even if you're rotating at 5 or more clinics during your PGY-3 year, it will just probably take a little longer than it did before. I recommend you don't decide you don't like outpatient until you've at least had 3 months of actually giving a patient medications to see some of them benefit.

 

[Trismegistus4]

(2) outpatient population enriched for people who don’t have major mental illnesses so much as problems with living in post industrial society with bad economy, where even if they do have a job it’s for positions like the people I’m having to contact in (1). End up listening to a fair amount of venting, feels like little is going to change.

The longer I live, the more convinced I become that 90% of "mental illness" is just our minds, which are wired to live in small, close-knit villages where everybody knows everybody else, being unable to deal with the artificialities of mass urban anonymity and social media.

(5) maybe I like inpatient, not outpatient? I do think even in med school I found “clinic days” (FM, OB/Peds clinic, etc) more draining than inpatient. Maybe the “flow” of slotted appointments just doesn’t sit right with me, compared to the flow of rounding and then budgeting time as appropriate to tasks.

It is one of the great myths of residency that outpatient is easier than inpatient. The opposite is true.

 

[Trismegistus4]

but the fundamental aspect of having scheduled appointments all day with "soft" diagnoses/"worried well" patients almost fills me with a sense of dread.

When I was in residency I used to joke that I'd prefer to treat the "worried well," but after 3 years of dealing with the wine-drinking, spa-going, UMC housewives who think they need Adderall and Xanax to run their Etsy shop or write their mommy blog, never again.

 

[TheRightMedication]

There is, necessarily, a part of human experience that sits astride the gulf in our knowledge about the brain and mind. Existential, philosophical, and practical problems on the one side, and brain pathology on the other.

If exploring that grey area in a way that benefits patients interests you, then you might enjoy outpatient.

If it doesn't interest you, I strongly recommend you hit the books anyways. Even in the most severe of mental illness, there will be a time when you have to navigate that ambiguity.

 

[Ludwig2000]

There is, necessarily, a part of human experience that sits astride the gulf in our knowledge about the brain and mind. Existential, philosophical, and practical problems on the one side, and brain pathology on the other.

If exploring that grey area in a way that benefits patients interests you, then you might enjoy outpatient.

If it doesn't interest you, I strongly recommend you hit the books anyways. Even in the most severe of mental illness, there will be a time when you have to navigate that ambiguity.

I’m interested - What books?

 

[J ROD]

The green grass is PGY 4.

 

[J ROD]

Outpatient is just a totally different animal. All of y’all are just focused on what ya know. Inpatient. As you do more outpatient and get to know patients things tend to get better. Most in my class have gone outpatient. With experience you learn to manage your day and make up time as needed. Half way through the year and you still hate it then okay. Probably an inpatient guy.

 

[TheRightMedication]

I’m interested - What books?

First off, you need your Tommy Szasz. If we're going to be tossing around the term "problems in living," you should read the man himself. He's technically wrong about everything but his critiques are truthy enough that its worth reading and thinking about. I picked up his books assuming I'd sneer at him the whole time but they left their mark on me.

Mainly, though, what I mean is to read the greats - Anything by Freud, any CBT book by Beck, and Carl Rogers is a must read. Jung is optional though in my view its so imaginative and fun, you're not reaping the full fruits of our heritage if you ignore him.

The goal is not to master any particular school of thought, but to demystify clinical psychology so that you can begin to use it practically.

A familiarity of psychological interventions (to say nothing of diet and exercise) gives you the flexibility to offer your patients so much more than medications. In turn, it gives you the confidence to make medication recommendations based on a wholesome knowledge of the field, not merely the pharmacologic piece of it. My patients know that if their pedantic, navel-gazing shrink recommends a medication, it is not for want of other options.

 

[jbomba]

Starting PGY 3 has been soul sucking for me and has only solidified I am an inpatient psychiatrist.
The every 30 minute grind is sooooo exhausting.

It's definitely a different strokes thing. I love churning through patients. Sitting around on consults waiting for the phone to ring or getting that call right before 430 and knowing you still have to go see a patient was brutally awful.

 

[mistafab]

PgY3 is just kind of boring. The acuity is so low. The people are much more capable. And you have so much time to do things. You talk about side effects, and they actually understand.

Where is the fire? I miss putting out fires. So and so reporting poor sleep, or showing up to clinic with mild psychosis… boring. Thank god for psychotherapy, otherwise I would fall asleep.

Where is the catatonia? where is the nms? What about delirium? When do I get to shock brains? I miss the action.

 

[Desired Member]

But I’d be interested in hearing from others who feel or have felt similarly.

Well ok, since you asked...
I too have COVID fatigue. Wearing a mask (particularly N95) and worry about getting sick w/COVID just makes me feel more tired and more resentful of the job.
If anything in PGY3 I felt there was never enough time. I was amazed at how much messed up stuff could happen to people in such a short period of time. Here's a formula for typical follow up visit for a clinic patient I saw 1-3 months ago:
Horrible social stressor (e.g. divorce, got kicked out of their apartment and living in their car, mom dying of COVID, etc.) + Horrible medication complication/compliance (e.g. decided to stop lamictal for a couple weeks before then restarting at 200mg -- despite WHAT WE TALKED ABOUT, and now they can't remember the last time they took it...was it 3 days...or 5 days?) + started using a new drug (kratom? delta 8? mushrooms?) + in the last 5 minutes, a safety bombshell (e.g. suddenly disclosing a serious eating disorder, episodes of passing out, etc.) = longer than 30 minute visit. And....no, they have not called to set up a therapy appointment yet.

 

[jbomba]

Well ok, since you asked...
I too have COVID fatigue. Wearing a mask (particularly N95) and worry about getting sick w/COVID just makes me feel more tired and more resentful of the job.
If anything in PGY3 I felt there was never enough time. I was amazed at how much messed up stuff could happen to people in such a short period of time. Here's a formula for typical follow up visit for a clinic patient I saw 1-3 months ago:
Horrible social stressor (e.g. divorce, got kicked out of their apartment and living in their car, mom dying of COVID, etc.) + Horrible medication complication/compliance (e.g. decided to stop lamictal for a couple weeks before then restarting at 200mg -- despite WHAT WE TALKED ABOUT, and now they can't remember the last time they took it...was it 3 days...or 5 days?) + started using a new drug (kratom? delta 8? mushrooms?) + in the last 5 minutes, a safety bombshell (e.g. suddenly disclosing a serious eating disorder, episodes of passing out, etc.) = longer than 30 minute visit. And....no, they have not called to set up a therapy appointment yet.

One thing that helped me immensely during the outpatient transition was the realization we shouldn't be working harder than our patients. I give them my absolute best and I will meet their efforts as far as they will go, but but I don't bend over backwards or hold their hands (when the effort isn't met). I also don't lose sleep because they're still engaging in the same maladaptive patterns we've discussed endlessly AND they still haven't gotten a therapist who might be better equipped to help them with. Once I got to this point, things got much easier on me.

 

[Mad Jack]

Alright, maybe it wasn’t exactly promised. But there is a definite, pervading narrative at my program that PGY-2 is the bad year. You just gotta get through PGY-2. “Only a month left of PGY-2! Dude you’re almost there!!” And on and on.

And in terms of hours spent at work, PGY-2 is our worst. BUT!
I’m finding myself utterly drained by 4-5pm, pretty much every week day so far this year. So much so that I’m wondering if there’s something going on with me.

Short of some kind of organic thing, differential diagnosis for my mental state includes:
(1) cumulative effect of meaningless and ineffectual bureaucratic tasks. Getting set up in a new system (outpatient sites), x y and z things don’t work on first try, have to re contact the various and amorphous administrative people or IT that sent/set up each thing to say it’s still not working. Hopefully decreases over time?

(2) outpatient population enriched for people who don’t have major mental illnesses so much as problems with living in post industrial society with bad economy, where even if they do have a job it’s for positions like the people I’m having to contact in (1). End up listening to a fair amount of venting, feels like little is going to change.

(3) Mismatch in expectations. In PGY-2 I was working hard, but this was very much expected given the narrative at this program. In PGY-3 I guess I thought… I’d be getting to do whatever I wanted? I don’t know what I expected, obviously it’s still residency, but I guess I at least expected to enjoy it more than PGY-2 and I’m actually enjoying it less.

(4) Too many different supervisors, all assigned to me without my input. The total amount of time in supervision meetings feels like a lot, and yet somehow I think I’d prefer it all be with one supervisor even if the same total time. Even better, one that I’d pick based on well-matching styles. Obviously there are pro’s to the variety, but in keeping with a recent Office Space reference on this forum, I feel like I have 8 different bosses. 8? 8, Bob.

(5) maybe I like inpatient, not outpatient? I do think even in med school I found “clinic days” (FM, OB/Peds clinic, etc) more draining than inpatient. Maybe the “flow” of slotted appointments just doesn’t sit right with me, compared to the flow of rounding and then budgeting time as appropriate to tasks.

(6) [wild card] COVID fatigue? Man am I sick wearing masks and all this.

That’s probably all I got.
We’ll see if this is all just an extended transition to a different environment and I’ll be back to my usual chipper self soon. But I’d be interested in hearing from others who feel or have felt similarly. I suppose also this may temper expectations of any younger residents who are also eagerly awaiting this sweet, sweet outpatient time. That’s not to say dread it, young grasshoppers, but be realistic.

Man, my outpatient experience was 80% severe mental Illness. Sounds like you've got it cozy

 

[Ludwig2000]

Man, my outpatient experience was 80% severe mental Illness. Sounds like you've got it cozy

For all I know, this could be my problem. I thought I'd like the "cozy"... and I actually chose not to sign up for the site(s) known to treat SMI patients. And now I do a bunch of menial tasks but never feel like I'm doing anything.

 

[samac]

For all I know, this could be my problem. I thought I'd like the "cozy"... and I actually chose not to sign up for the site(s) known to treat SMI patients. And now I do a bunch of menial tasks but never feel like I'm doing anything.

I signed up for the SPMI patients at the community clinic but it’s so overworked I’m grinding through meeting patients for the first time in 30 minute slots, have been overbooked. Barely have time for “hi. Ya doing okay? Good here’s your meds”. Makes it hard to feel like I’m making a difference. I’m also the only physician on premise that day and I find that terrifying as a fresh pgy. 3.
/rant

 

[Stagg737]

I'll address your points individually as I'm now an attending in a position with multiple settings but do not see outpatients. However, a couple of general things first. I agree with the previous posters who said to not work harder than your patients (outside of certain SMI/SMPI situations) and given outpatient more time before casting final judgment. I HATED outpatient for the first 6 months of third year and hated it slightly less during the next 6 months once my schedule was corrected. Fourth year wasn't nearly as bad (half day twice a week with patients we chose to keep), but I still never looked forward to outpatient clinic. By the end of residency, there was a handful of patients that I did actually wish I could have kept seeing, but overall I'm still grateful to be done with the outpatient side of things for now.

(1) cumulative effect of meaningless and ineffectual bureaucratic tasks. Getting set up in a new system (outpatient sites), x y and z things don’t work on first try, have to re contact the various and amorphous administrative people or IT that sent/set up each thing to say it’s still not working. Hopefully decreases over time?

This sucks, but should get better over 2-3 months as you get into the flow of things.

(2) outpatient population enriched for people who don’t have major mental illnesses so much as problems with living in post industrial society with bad economy, where even if they do have a job it’s for positions like the people I’m having to contact in (1). End up listening to a fair amount of venting, feels like little is going to change.

(6) [wild card] COVID fatigue? Man am I sick wearing masks and all this.

This is one of the biggest problems with outpatient and was addressed already. One thing to add is to figure out what resources are available within your clinic and locally. Ime this was better inpatient as you have SW available to help provide those resources to everyone. At decent CMHCs, CMs can be very helpful with this. In the lower acuity clinics, these are resources you have to learn about or ask about yourself. There's a

(3) Mismatch in expectations. In PGY-2 I was working hard, but this was very much expected given the narrative at this program. In PGY-3 I guess I thought… I’d be getting to do whatever I wanted? I don’t know what I expected, obviously it’s still residency, but I guess I at least expected to enjoy it more than PGY-2 and I’m actually enjoying it less.

You're still a resident, as the year goes on you'll hopefully get more autonomy like the first two years should be. The advantage of 3rd year at a lot of programs is less/no call, a (mostly) set schedule, and the ability to plan for the following days. It doesn't necessarily mean less work, and depending on the EMR can be a lot more.

(4) Too many different supervisors, all assigned to me without my input. The total amount of time in supervision meetings feels like a lot, and yet somehow I think I’d prefer it all be with one supervisor even if the same total time. Even better, one that I’d pick based on well-matching styles. Obviously there are pro’s to the variety, but in keeping with a recent Office Space reference on this forum, I feel like I have 8 different bosses. 8? 8, Bob.

This can be really frustrating but can be really beneficial in terms of seeing different treatment styles. Try and find 2 or 3 of those people you feel are really good, preferable ones with slightly different styles and learn as much as you can from them. It not only helps centralize learning a bit more but can also help with efficiency in terms of getting through the days.

(5) maybe I like inpatient, not outpatient? I do think even in med school I found “clinic days” (FM, OB/Peds clinic, etc) more draining than inpatient. Maybe the “flow” of slotted appointments just doesn’t sit right with me, compared to the flow of rounding and then budgeting time as appropriate to tasks.

The rigidity of the schedule is one of the most prominent things I dislike about outpatient. Some appointments may only take 10 minutes, but some may require 40-50 and having a set schedule is not conducive to those needs. If you like a set schedule it can be nice, but if you want/need flexibility it can be very frustrating.

It's definitely a different strokes thing. I love churning through patients. Sitting around on consults waiting for the phone to ring or getting that call right before 430 and knowing you still have to go see a patient was brutally awful.

This is why you set a time to call it for the day and anything that comes in later that's not stat gets taken care of tomorrow. The ebb and flow of busyness isn't for everyone, but the last-minute consult is something that can easily be managed with policies most of the time.

 

[comp1]

Outpatient is horrible. I strongly disliked the vast majority of it. The good news is that inpatient is still waiting for you to come back!

 

[Ludwig2000]

After 9 months of outpatient I’m going to say…
I still don’t like it.

To be honest, I think I’m too burnt out to even have the energy to post on sdn anymore. (My post history reads like that of a one time idealist becoming increasingly angry and then reclusive).

I’m not even seeing that many patients... 4-7 per day slotted for an hour each. Majority do show up and do fill the hour. But not all. Average 2 hours supervision per day, either 1:1 or group.
Overall this should be cushy but it’s ever more draining to me. I still get home and just lie down. I’m typing this horizontally.

Still like psychiatry in theory; I like both the biological and the most psychodynamic of literature. But find myself hating the practice of it, at least in its current incarnation

Maybe just need a vacation

“And all my friends were vampires. Didn’t know they were vampires. Turns out I was a vampire myself, in the Devil Town” [-Daniel Johnston]

 

[clausewitz2]

After 9 months of outpatient I’m going to say…
I still don’t like it.

To be honest, I think I’m too burnt out to even have the energy to post on sdn anymore. (My post history reads like that of a one time idealist becoming increasingly angry and then reclusive).

I’m not even seeing that many patients... 4-7 per day slotted for an hour each. Majority do show up and do fill the hour. But not all. Average 2 hours supervision per day, either 1:1 or group.
Overall this should be cushy but it’s ever more draining to me. I still get home and just lie down. I’m typing this horizontally.

Still like psychiatry in theory; I like both the biological and the most psychodynamic of literature. But find myself hating the practice of it, at least in its current incarnation

Maybe just need a vacation

“And all my friends were vampires. Didn’t know they were vampires. Turns out I was a vampire myself, in the Devil Town” [-Daniel Johnston]

Sorry to hear it's not getting better. At the end of the day outpatient practice isn't for everyone. It is easy to feel burdened with responsibility for your patients, many of whom make very poor decisions, and in traditional outpatient practice you're the one who has to make all the choices about what to do about it.

Honestly though I wonder if being so idle has a lot to do with your dislike for it. Hurry up and wait is not a pleasant proposition. More than hours, burnout is predicted by feelings of powerlessness and pointlessness. If it doesn't feel like you're accomplishing much, that's way more likely to make you crispy than just putting in a lot of hours.

Speaking of pointlessness, if your case load is like the majority of patients at most resident clinics, you are dealing with a lot of hardcases, as it were. These are not the people who are going to get better any time soon by and large.

What do you think you hate about the current incarnation of psychiatry?

 

[erg923]

After 9 months of outpatient I’m going to say…
I still don’t like it.

To be honest, I think I’m too burnt out to even have the energy to post on sdn anymore. (My post history reads like that of a one time idealist becoming increasingly angry and then reclusive).

I’m not even seeing that many patients... 4-7 per day slotted for an hour each. Majority do show up and do fill the hour. But not all. Average 2 hours supervision per day, either 1:1 or group.
Overall this should be cushy but it’s ever more draining to me. I still get home and just lie down. I’m typing this horizontally.

Still like psychiatry in theory; I like both the biological and the most psychodynamic of literature. But find myself hating the practice of it, at least in its current incarnation

Maybe just need a vacation

“And all my friends were vampires. Didn’t know they were vampires. Turns out I was a vampire myself, in the Devil Town” [-Daniel Johnston]

To the highlighted: Probably not, actually. Your sentence before that kind of clenches it, right? You don't have to like everything in your training. Sometimes people just don't like stuff and/or cant tolerate it. I'm interested in weather, doesn't mean I would like to be a broadcast meteorologist, right? But maybe I could work for NOAA though?

Do NOT go home directly from work if getting off at 4,5,6 most days. Schedule a group workout class for most of those days. However stupid or ridiculous they may have become. Then just crash or do social stuff. Swim if you can. Learn something new: Golf, tennis, or buy a kayak and see what you can find around you.

 

[Ludwig2000]

Sorry to hear it's not getting better. At the end of the day outpatient practice isn't for everyone. It is easy to feel burdened with responsibility for your patients, many of whom make very poor decisions, and in traditional outpatient practice you're the one who has to make all the choices about what to do about it.

Honestly though I wonder if being so idle has a lot to do with your dislike for it. Hurry up and wait is not a pleasant proposition. More than hours, burnout is predicted by feelings of powerlessness and pointlessness. If it doesn't feel like you're accomplishing much, that's way more likely to make you crispy than just putting in a lot of hours.

Speaking of pointlessness, if your case load is like the majority of patients at most resident clinics, you are dealing with a lot of hardcases, as it were. These are not the people who are going to get better any time soon by and large.

What do you think you hate about the current incarnation of psychiatry?

Thank you

Yeah I think what I hate about current incarnation is
1. Powerlessness
2. Pointlessness
3 (bonus round). Documentation in EMRs with required fields/checkboxes

 

[erg923]

Thank you

Yeah I think what I hate about current incarnation is
1. Powerlessness
2. Pointlessness
3 (bonus round). Documentation in EMRs with required fields/checkboxes

Talk about #2 more (yes, yes ha-ha). But Beck's notion of "Pleasure and Mastery" will probably never go away as being exceedingly relevant for our modern lives and work life.

 

[Ludwig2000]

It feels pointless because:
Most of my patients would be better off learning by doing, when it comes to coping / self soothing. Which is really all they need.
Instead, they rely on me and pharmaceuticals.
Thus, the one thing that’s getting in the way of their gaining mastery over their lives, is me, the psychiatrist.
Perhaps there are others out there who could still have them jump into the deep end, and stand by and support them through the process of learning to doggy paddle.
Not to mention, there are probably things about modernity that we’d be better off taking head on as the problems they are, rather than as acting as enablers of a depression-o-genic society, and pretending it’s normal for >10% of people to need medication to get through their dreary existence

 

[erg923]

It feels pointless because:
Most of my patients would be better off learning by doing, when it comes to coping / self soothing. Which is really all they need.
Instead, they rely on me and pharmaceuticals.
Thus, the one thing that’s getting in the way of their gaining mastery over their lives, is me, the psychiatrist.
Perhaps there are others out there who could still have them jump into the deep end, and stand by and support them through the process of learning to doggy paddle.
Not to mention, there are probably things about modernity that we’d be better off taking head on as the problems they are, rather than as acting as enablers of a depression-o-genic society, and pretending it’s normal for >10% of people to need medication to get through their dreary existence

Then do that. Or help them toward taking these steps, rather. Via medications.... and your knowledge or human behavior, relationships, empathy, boundaries, thought biases and distortions, basic principles of learning/reinforcement, etc. Alot of this is a therapist's job too? Where are they in your system? Are you collaborating or at least talking with them? You can't do that for 20-30 different patients every week of course, but I'm sure at least half of those probably aren't even in psychotherapy anyway, no?

I can agree that the last thing some people need, especially those impoverished of money or resources or opportunity is Psychiatry and/or ongoing "Psychiatric Services." Wasteful and Iatrogenic many times.

I would also read about "detached compassion" if I were you.

 

[whopper]

If all depends on the program. In my residency program the hard work was so much on running the inpatient unit and ER psych that was almost completely PGY 1 and 2. Outpatient was a breeze and that was PGY-3 and 4. by 4th year we were working less than 40 hours a week and hardly had any call.

 

[Sushirolls]

I miss residency days. Such good social circles, won the lottery in that regard.

Always a resident or 4 to go to happy hour with and gripe. Or share moonlighting stories / opportunities with.
Plus moments of hanging out with neurology/IM/surgical etc at times, reminds you how things can be so much worse.

Ultimately, try to extrapolate the positive from residency clinic how to manage the tougher cases. It's a slower tempo, less victories in resident clinic, but if you can learn to keep to not take home your work now, better off you'll be for the long haul. Find the healthier coping / buffers. And there is the light at the end of the tunnel, some day, you too will hand these patients off to a green PGY-III.

 

[comp1]

Ugh, I hated PGY3. I hated outpatient in general because our meds are really approved (and helpful) for at least moderate illness and generally more for severe illnesses. You are less likely to see these in outpatient. Most patients in outpatient seemed to really need talk therapy a heck of a lot more than a 5th or 6th med trial. Further, the sort of patients attracted to resident clinics was not helpful because they didn't seem to realize that going to an academic center meant that you would primarily (almost exclusively) be working with trainees, not some famous doctor showing up in ads or on the news. Quite the opposite, you were likely to be their first therapy patient! The upside...there's a heck of a lot of other stuff to do out there!

 

[Auvelity]

As a PGY-3 can I say… same!
I’m exhausted all the time. I don’t know if I need bupropion but I don’t have enough energy to study or do anything anymore.
Outpatient is draining…
I just hope it gets better with time

 

[samac]

If all depends on the program. In my residency program the hard work was so much on running the inpatient unit and ER psych that was almost completely PGY 1 and 2. Outpatient was a breeze and that was PGY-3 and 4. by 4th year we were working less than 40 hours a week and hardly had any call.

My program is overall much easier 3rd 4th year but the work isn’t as satisfying for me I don’t think.
My clinic attracts a lot of worried well and personality pathology that have been on 15 different medicines and nothing helps. I just feel like I’m constantly spinning my wheels not making a difference for most patients.
I can’t wait to be back in a hospital.

 

[annoyedpsychiatrist]

My program is overall much easier 3rd 4th year but the work isn’t as satisfying for me I don’t think.
My clinic attracts a lot of worried well and personality pathology that have been on 15 different medicines and nothing helps. I just feel like I’m constantly spinning my wheels not making a difference for most patients.
I can’t wait to be back in a hospital.

thats because BPD disorders is probably like 10-15% of outpatient, then you have people who are looking for the magic pill. It is very easy, VERY easy to get jaded by these people and let it negatively influence your perception of your contribution. Though in the clinic, we focus more on the failures more than the successes, because we see the people who never do better more frequently quite often and we very easily forget the ones weve helped/stabilized.

Our goal is not to fix people in the clinic, its to improve insight and offer guidance, but ultimately patient has to take the advice. Medications are only one part of the equation and i make sure i instill that in my patient's brains. Some people probably just come because talking to someone who listens is the thing they want the most.

 

[Ludwig2000]

Then do that. Or help them toward taking these steps, rather. Via medications.... and your knowledge or human behavior, relationships, empathy, boundaries, thought biases and distortions, basic principles of learning/reinforcement, etc. Alot of this is a therapist's job too? Where are they in your system? Are you collaborating or at least talking with them? You can't do that for 20-30 different patients every week of course, but I'm sure at least half of those probably aren't even in psychotherapy anyway, no?

I can agree that the last thing some people need, especially those impoverished of money or resources or opportunity is Psychiatry and/or ongoing "Psychiatric Services." Wasteful and Iatrogenic many times.

I would also read about "detached compassion" if I were you.

I’m doing meds + therapy for the majority of my patients. I have several I see weekly and more who I see every 2 weeks.
You are right that I need to grok detached compassion

 

[randomdoc1]

Yea, I don't think a land of milk and honey exists xD. But you can still have it pretty good once you find your niche. I work with the worried well and boy, residency does not train you for it. Affluenza especially, it is some of the WORST personality pathology EVER and the parents often entrench it as the family embarks on a life long mission to find what does not exist. But hopefully we each over time and not over too much time find what works for us and not get too hard on ourselves about our realistic limitations. At the end of the day, it's not our problem to fix. We can't fix it. Focus on improvement. And in many many settings, even the severely chronically ill, the psychotherapy makes a huge difference and can minimize the unnecessary cycling through of meds. People benefit more than you think from you just being there for them, when they sense it is genuine. It's been an incredible experience overtime as I learned to even do some psychotherapy through active psychosis (but they still need to keep their antipsychotic on though lol).

 

[Desired Member]

My program is overall much easier 3rd 4th year but the work isn’t as satisfying for me I don’t think.
My clinic attracts a lot of worried well and personality pathology that have been on 15 different medicines and nothing helps. I just feel like I’m constantly spinning my wheels not making a difference for most patients.
I can’t wait to be back in a hospital.

It seems like there’s actually just personality disorders (mostly borderline) everywhere. Inpatient, outpatient, hasn’t seemed to matter. I tended to dislike inpatient more as it tended to be only dumpster fires though outpatient can be that way too sometimes. I find outpatient exhausting but wouldn’t want to manage inpatients on my own. I like managing mania inpatient but that was such a small fraction compared to the loads of borderlines and antisocial malingerers inpatient.

 

[Stagg737]

After 9 months of outpatient I’m going to say…
I still don’t like it.

To be honest, I think I’m too burnt out to even have the energy to post on sdn anymore. (My post history reads like that of a one time idealist becoming increasingly angry and then reclusive).

I’m not even seeing that many patients... 4-7 per day slotted for an hour each. Majority do show up and do fill the hour. But not all. Average 2 hours supervision per day, either 1:1 or group.
Overall this should be cushy but it’s ever more draining to me. I still get home and just lie down. I’m typing this horizontally.

Still like psychiatry in theory; I like both the biological and the most psychodynamic of literature. But find myself hating the practice of it, at least in its current incarnation

Maybe just need a vacation

“And all my friends were vampires. Didn’t know they were vampires. Turns out I was a vampire myself, in the Devil Town” [-Daniel Johnston]

As a PGY-3 can I say… same!
I’m exhausted all the time. I don’t know if I need bupropion but I don’t have enough energy to study or do anything anymore.
Outpatient is draining…
I just hope it gets better with time

My program is overall much easier 3rd 4th year but the work isn’t as satisfying for me I don’t think.
My clinic attracts a lot of worried well and personality pathology that have been on 15 different medicines and nothing helps. I just feel like I’m constantly spinning my wheels not making a difference for most patients.
I can’t wait to be back in a hospital.

Agree with previous posters that resident clinics are often poor representations of actual outpatient practice, especially if you go into PP on your own or with a group of other psychiatrists. It's no secret how much I hated PGY-3, so much so that if it were my intern year I probably would have switched fields. I think a big part of it for me was thinking that outpatient would mean "better" patients in the sense that they'd have better insight, more motivation, and be generally functional, when the reality was that most of them were just a different kind of train wreck. No, not all outpatients are like this, but many are and they're often drawn to academic centers and the CMHCs that residents work in.

That being said, outpatient as an attending is tolerable, especially only doing 6 hours per week. I still work through an academic center, but I have much more freedom in terms of how I practice/bill. Documentation is easier. I'm still working on minimizing fluff, but not having to meet documentation expectations or justify every decision to academic attendings is nice. I still struggle with not feeling responsible for the trajectory of my patients and the lack of control over their care/actions at times, but burnout has actually helped me not care as much and be more conscious that it's just out of my control. I can also select who will actually benefit from ongoing care and who I continue to see vs who I refer back to PCP with recommendations for various resources. I still think I would loathe doing outpatient full time, and I don't really enjoy my outpatient clinic, but it does give me some leverage in terms of my other responsibilities and a nice little pay bump as I bill a lot of 90792s and therapy add-ons.

It seems like there’s actually just personality disorders (mostly borderline) everywhere. Inpatient, outpatient, hasn’t seemed to matter. I tended to dislike inpatient more as it tended to be only dumpster fires though outpatient can be that way too sometimes. I find outpatient exhausting but wouldn’t want to manage inpatients on my own. I like managing mania inpatient but that was such a small fraction compared to the loads of borderlines and antisocial malingerers inpatient.

I actually don't mind that so much because once you make them uncomfortable enough they usually ask to leave on their own. Sometimes they'll even say something d***ing enough that you can document that patient admitted to malingering/seeking and would not recommend future inpatient admission if they're frequent flyers.

 

[samac]

Agree with previous posters that resident clinics are often poor representations of actual outpatient practice, especially if you go into PP on your own or with a group of other psychiatrists. It's no secret how much I hated PGY-3, so much so that if it were my intern year I probably would have switched fields. I think a big part of it for me was thinking that outpatient would mean "better" patients in the sense that they'd have better insight, more motivation, and be generally functional, when the reality was that most of them were just a different kind of train wreck. No, not all outpatients are like this, but many are and they're often drawn to academic centers and the CMHCs that residents work in.

That being said, outpatient as an attending is tolerable, especially only doing 6 hours per week. I still work through an academic center, but I have much more freedom in terms of how I practice/bill. Documentation is easier. I'm still working on minimizing fluff, but not having to meet documentation expectations or justify every decision to academic attendings is nice. I still struggle with not feeling responsible for the trajectory of my patients and the lack of control over their care/actions at times, but burnout has actually helped me not care as much and be more conscious that it's just out of my control. I can also select who will actually benefit from ongoing care and who I continue to see vs who I refer back to PCP with recommendations for various resources. I still think I would loathe doing outpatient full time, and I don't really enjoy my outpatient clinic, but it does give me some leverage in terms of my other responsibilities and a nice little pay bump as I bill a lot of 90792s and therapy add-ons.



I actually don't mind that so much because once you make them uncomfortable enough they usually ask to leave on their own. Sometimes they'll even say something d***ing enough that you can document that patient admitted to malingering/seeking and would not recommend future inpatient admission if they're frequent flyers.

I can see how it would be a little better as an attending. Looking at 1 job that’s 50/50 inpatient outpatient and 1 that’s all inpatient, split pays more. But I’m so burnt out.

Your second point I have done a lot of and probably why I feel fine with inpatient. Saying something along the lines of, “Patient demonstrates pattern of maladaptive coping strategies in response to stressors. Patient my has had x number of admissions and has shown minimal benefit from inpatient treatment. Patient at chronically elevated risk given x, y, z but inpatient hospitalization unlikely to mitigate these risks.”

 

[sloh]

Agree with previous posters that resident clinics are often poor representations of actual outpatient practice, especially if you go into PP on your own or with a group of other psychiatrists. It's no secret how much I hated PGY-3, so much so that if it were my intern year I probably would have switched fields. I think a big part of it for me was thinking that outpatient would mean "better" patients in the sense that they'd have better insight, more motivation, and be generally functional, when the reality was that most of them were just a different kind of train wreck. No, not all outpatients are like this, but many are and they're often drawn to academic centers and the CMHCs that residents work in.

That being said, outpatient as an attending is tolerable, especially only doing 6 hours per week. I still work through an academic center, but I have much more freedom in terms of how I practice/bill. Documentation is easier. I'm still working on minimizing fluff, but not having to meet documentation expectations or justify every decision to academic attendings is nice. I still struggle with not feeling responsible for the trajectory of my patients and the lack of control over their care/actions at times, but burnout has actually helped me not care as much and be more conscious that it's just out of my control. I can also select who will actually benefit from ongoing care and who I continue to see vs who I refer back to PCP with recommendations for various resources. I still think I would loathe doing outpatient full time, and I don't really enjoy my outpatient clinic, but it does give me some leverage in terms of my other responsibilities and a nice little pay bump as I bill a lot of 90792s and therapy add-ons.



I actually don't mind that so much because once you make them uncomfortable enough they usually ask to leave on their own. Sometimes they'll even say something d***ing enough that you can document that patient admitted to malingering/seeking and would not recommend future inpatient admission if they're frequent flyers.

Guess there is a silver lining to burnout haha

 

[MacDonaldTriad]

Zeroquel is very sedative because the only side effects are sedation and metabolic syndrome. It seems that this has been enough for us to excuse the consensus that it doesn't seem to work.

 

[Stagg737]

Guess there is a silver lining to burnout haha

It's certainly helped me channel my inner Peter...

 

[Mad Jack]

I've gotta say- to anyone that hated 3rd year of general psych, second year of CAP fellowship is the same times two. Double the helplessness, double the stress, double the suffering all around care of lack of patient agency and significant family factors.