Picking a Program

[jdwmont]

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I'm currently an MS3 with an interest in psych, but am still not sure I am OK with hanging up my stethoscope and never touching a scalpel again. That being said, psych is easily the most fascinating, rewarding & existentially challenging specialty I have worked in thus far. So, I would appreciate any advice you might have regarding programs where residents can continue to develop more traditionally IM skills after intern year. I am considering psych/IM residencies, but feel that I would likely practice psych exclusively, with the possibility of C/L fellowship.

I realize that it is still early in the game, but any advice would be appreciated.

 

[diagonal]

Pretty sure no psych program is going to involve scalpels. Pick a team.

 

[toothless rufus]

Pretty sure no psych program is going to involve scalpels. Pick a team.

Haha! If one does: RUN!

 

[st2205]

Pretty sure no psych program is going to involve scalpels. Pick a team.

The ones in Oklahoma do, if you're a DO.

 

[nancysinatra]

You mean "put down a retractor." Med students don't use scalpels. If they're lucky they might get to apply suction.

 

[st2205]

You mean "put down a retractor." Med students don't use scalpels. If they're lucky they might get to apply suction.

Was not my experience.

 

[diagonal]

You mean "put down a retractor." Med students don't use scalpels. If they're lucky they might get to apply suction.

Surgeons barely even use scalpels.

OP, are you ready to put down that bovie? (that you haven't touched yet)

 

[shan564]

A junior resident once asked me if I wanted to do a procedure (which involved a scalpel) because she'd never done it before, the senior resident was gone for a job interview, and the attending was doing procedures all afternoon. I thought about trying it, but then I realized that I'd never actually applied a scalpel to skin before.

 

[Shufflin]

I agree, psychiatry is the most fascinating, rewarding and existentially challenging specialty. I love the field. When its your thoughts and words in a session, and not a scalpel or medication necessarily, that helps someone manage depression or anxiety, how much more direct can you get in terms of therapeutic modality? You walk away feeling like you helped someone directly, and I know a few doctors in other fields who miss this feeling. Cherish it.

My suggestion is to keep your eye on psychiatry. In residency, you can then figure out if a C/L fellowship is your goal. I don't advise going the IM/Psych route. C/L psychiatrists use their stethoscope every day.

 

[hamstergang]

I'm currently an MS3 with an interest in psych, but am still not sure I am OK with hanging up my stethoscope and never touching a scalpel again.

I still play with my scalpel, but I'm not sure if I'm supposed to.

As was said in a different ongoing thread, you still need to be doing physical exams on your patients, so depending on where you end up working you won't literally hang up your stethoscope (though you certainly can depending on what you're doing).

Speaking more figuratively about hanging up the stethoscope, you're still a doctor as a psychiatrist. Still thinking like a doctor, still having to address IM complaints from patients and take them into consideration even if you aren't the primary team handling them. I don't know, however, which residency programs if any really have you focus on this aspect. Well, one I interviewed at comes to mind -- Johns Hopkins has you do 2 months in the ICU on top of the 4 IM floors months, I believe. That was the most IM-focused program I saw.

 

[deleted452516]

Well, one I interviewed at comes to mind -- Johns Hopkins has you do 2 months in the ICU on top of the 4 IM floors months, I believe. That was the most IM-focused program I saw.

Johns Hopkins has 6 weeks ICU/CCU, which is included in the 4 total months of medicine.

see below

 

[hamstergang]

Johns Hopkins has 6 weeks ICU/CCU, which is included in the 4 total months of medicine.

http://www.hopkinsmedicine.org/psychiatry/education/residency_general/2012_clinical_rotations.pdf

It says 6 months medicine total (though it adds up to 5.5): 4 months inpatient medicine. 1 month CICU. 1/2 month MICU.

 

[deleted452516]

oh snap, you're right! my preinterview feasting tonight left me somewhat impaired.

just a wafer-thin mint- it's only a tiny little thin one

 

[peppy]

I'd definitely encourage you to focus on programs with strong CL fellowships. I think you'll find that there is enough need for strong general medical knowledge in CL psych to satisfy you - if you get into a program where CL psychiatry is well-respected and gets interesting cases (the zebras, not just a ton of delirium consults).

 

[jdwmont]

Thanks for the responses, especially regarding strong CL programs. I'm not saying I want to do both med & psych, just that I've found it a little off-putting when patients are admitted to psych & auscultation is done over three layers of clothing (ie, "heart... present..."). Just seems like a waste & disservice to me. Students can have pretty significant minor procedural experience at my institution (if you look for it), so I suppose that has biased my perspective somewhat. Family is definitely still on my list, a little of both specialties...

 

[toothless rufus]

Thanks for the responses, especially regarding strong CL programs. I'm not saying I want to do both med & psych, just that I've found it a little off-putting when patients are admitted to psych & auscultation is done over three layers of clothing (ie, "heart... present..."). Just seems like a waste & disservice to me. Students can have pretty significant minor procedural experience at my institution (if you look for it), so I suppose that has biased my perspective somewhat. Family is definitely still on my list, a little of both specialties...

I agree any PE done by any physician should be legitimate, I just think the fact that generally the pts admitted to psych are usually "medically cleared" and usually are not going to nor are they expected to have any acute medical complaints, nor anything less than a benign exam. This unfortunately seems to lull the psychiatrically inclined professionals to sometimes half-ass it to just go through the required motions. When I do do PE's, sometimes I feel the pull myself but resist it and try to do it as if I were a medical student getting graded on it in lab. I want to retain very good basics.

 

[notdeadyet]

I agree any PE done by any physician should be legitimate, I just think the fact that generally the pts admitted to psych are usually "medically cleared" and usually are not going to nor are they expected to have any acute medical complaints, nor anything less than a benign exam.

Jesus, I'd love to practice where you do. Up where I'm at, there seems to be a constant barrage to our county and tertiary inpatient psych hospitals from Kaiser and the like in which they have VERY dodgy interpretations of what it means to be medically stable. I spend more time scrutinizing the paperwork before accepting a transfered admission than I do conducting a physical exam of a patient myself.

 

[snowowl]

jdwmont-

I have felt the exact same sentiments starting my rotations as a 3rd year. It has been so frustrating to be on medicine services that have little (if any) resources for caring for patients with decompensated psychiatric disorders and psychiatry services that have few (if any) resources to care for patients with any condition that isn't found in the DSM.

I've spent a lot of time familiarizing myself with programs that take pride in "strong psychosomatics" as well as Med-Psych combined programs. But I have to say that I have been most impressed with residency programs that have training in a combined med-psych unit and in "medical home" style integrated psych & primary care outpatient centers.

For the former, I've been looking at places like Iowa and Mayo, though I think there are others popping up around the country in a variety of settings. For outpatient care, it seems to be more rare, especially when it comes to residency training--with the exception of major VA centers, where co-located psych & primary care has been up and running for a while (I'm not sure how long exactly, but long enough to do projects like this: http://www.ncbi.nlm.nih.gov/pubmed/21532086).

Also--fyi: there was a thread about med-psych units on SDN a while back: http://forums.studentdoctor.net/showthread.php?t=816598

I've heard that there are some IM and FM programs out there that are more on-board with this kind of integration, too, though honestly I've had trouble coming up with good examples. It would be great to train in a place where the general medicine service cares for patients with decompensated mental illness with the same expertise and composure that they muster for patients with other complicated and misunderstood chronic diseases (like cancer, HIV, or TB).

If anyone else knows of good programs with institutional support for this kind of training, please chime in!

 

[Fastball32]

I remember being in a similar situation as you when I was a Medical Student. Even as a PGY-1 Psych Resident, I recall thinking how deterred most of my Attendings were at treating "minor" hypertension and how quick they wanted to consult medicine for non-urgent medical issues.

Well, now that I'm almost done with my training, I realize that there is a reason why Psych is a 4 year program, even longer than the procedure heavy fields of IM or Family Medicine. Keeping up with all the IM/Family literature, along with mind/behavior procedures in Psychiatry would be a monumental task. The first years of Psychiatry training may focus on the basics of psychopharmacology, however the later years often focus more on therapy procedures.

That said, you have a fair bit of options. C&L or Geriatrics would require a good knowledge of pathophysiology. You could focus on procedures such as ECT or TMS, however those don't really require pathophysiology knowledge. Sleep or Pain Fellowships can be had through General Psychiatry as well. Addiction Psychiatry delves into detox and medication management too.

It sounds like you, like a lot of us, were attracted to Psychiatry for what it is. Don't let what Psychiatry is not, deter you away from it.

 

[vistaril]

C/L psychiatrists use their stethoscope every day.

This is not true. I know a good number of academic C/L psychiatrists, and Im not sure I have ever seen one with a stethoscope. I can't think of any good reason why a psychiatrist would need their stethoscope on a consult.

 

[shan564]

This is not true. I know a good number of academic C/L psychiatrists, and Im not sure I have ever seen one with a stethoscope. I can't think of any good reason why a psychiatrist would need their stethoscope on a consult.

I don't think I've seen many C/L psychiatrists walk around with a stethoscope, but C/L supervisors have occasionally asked to borrow my stethoscope (since I'm a med student, so I usually have one). Specifically, I'm thinking about a guy with ?clozapine-induced cardiopulmonary dysfunction and a lady with ?alcoholic cardiomyopathy. And I can see the rationale in checking for infective endocarditis in a psych patient with a history of IVDU.

Of course, no psychiatrist is expected to check for any of those things, but you did go to medical school, so I think it's perfectly reasonable to check it out.

 

[vistaril]

I don't think I've seen many C/L psychiatrists walk around with a stethoscope, but C/L supervisors have occasionally asked to borrow my stethoscope (since I'm a med student, so I usually have one). Specifically, I'm thinking about a guy with ?clozapine-induced cardiopulmonary dysfunction and a lady with ?alcoholic cardiomyopathy. .

makes absolutely no sense.....if you're seeing a patient on consults(say a cardiology or medicine service) with clozaril induced cardiosomething, then the consult is obviously going to be: Pt on clozaril. Now with cardiosomething. Recs on med options(decreasing clozaril, changing antipsychotics, etc)?

The consult is most definately NOT: Is this cardiosomething dysfunction? They may be asking you if clozaril is the likely offender, but what they are most definately not asking you to do is listen and question them on the physical exam findings.

 

[shan564]

makes absolutely no sense.....

I hate to diagnose people online, but does this (and half of vistaril's other posts) sound like splitting?

if you're seeing a patient on consults(say a cardiology or medicine service) with clozaril induced cardiosomething, then the consult is obviously going to be: Pt on clozaril. Now with cardiosomething. Recs on med options(decreasing clozaril, changing antipsychotics, etc)?

The consult is most definately NOT: Is this cardiosomething dysfunction? They may be asking you if clozaril is the likely offender, but what they are most definately not asking you to do is listen and question them on the physical exam findings.

I agree that you don't HAVE to listen and question them, but it doesn't hurt. The reason I gave the example of clozapine-induced myocarditis is because I once saw a patient at ~3pm with that sort of presentation, and they'd consulted psych because they wanted us "on board" due to the patient's history of psychosis. The patient's presumptive diagnosis (from an inpatient psych unit) was pneumonia and he was on contact precautions. They'd ordered an echo, but I was the first person to see it because it was later in the day and the result had just come back. Cardiology and ID hadn't considered clozapine-induced myocarditis, and it was the C/L psych team that made the diagnosis. We would have stopped the clozapine either way, but it saved the patient from a few days of contact precautions and unnecessary treatment for pneumonia. I'm sure we could have made the diagnosis without listening to his lungs and his heart, but it helped.

I can tell you a similar story about a lady with macrocytic anemia due to alcohol use. She had normocytic anemia with mildly increased RDW, and she denied ever drinking alcohol. I went down to the hematology lab to look at the blood smear, and it was clear that she had both macrocytes and microcytes with no megaloblasts - classic picture of iron deficiency combined with alcohol-related anemia, which didn't show up on the CBC because the microcytes and macrocytes cause the MCV to average out. Because of that blood smear, we were able to be very certain that she was lying about her alcohol use, and when she heard that one of the blood tests showed signs of heavy alcohol abuse, she fessed up.

The point is - you don't have to use general medical skills in psychiatry, but it can help in some situations.

 

[twright]

I hate to diagnose people online, but

Not advisable

 

[vistaril]

I hate to diagnose people online, but does this (and half of vistaril's other posts) sound like splitting?



I agree that you don't HAVE to listen and question them, but it doesn't hurt. The reason I gave the example of clozapine-induced myocarditis is because I once saw a patient at ~3pm with that sort of presentation, and they'd consulted psych because they wanted us "on board" due to the patient's history of psychosis. The patient's presumptive diagnosis (from an inpatient psych unit) was pneumonia and he was on contact precautions. They'd ordered an echo, but I was the first person to see it because it was later in the day and the result had just come back. Cardiology and ID hadn't considered clozapine-induced myocarditis, and it was the C/L psych team that made the diagnosis. We would have stopped the clozapine either way, but it saved the patient from a few days of contact precautions and unnecessary treatment for pneumonia. I'm sure we could have made the diagnosis without listening to his lungs and his heart, but it helped.

I can tell you a similar story about a lady with macrocytic anemia due to alcohol use. She had normocytic anemia with mildly increased RDW, and she denied ever drinking alcohol. I went down to the hematology lab to look at the blood smear, and it was clear that she had both macrocytes and microcytes with no megaloblasts - classic picture of iron deficiency combined with alcohol-related anemia, which didn't show up on the CBC because the microcytes and macrocytes cause the MCV to average out. Because of that blood smear, we were able to be very certain that she was lying about her alcohol use, and when she heard that one of the blood tests showed signs of heavy alcohol abuse, she fessed up.

The point is - you don't have to use general medical skills in psychiatry, but it can help in some situations.

lol....what these examples really prove is that a lot of the people(on psychiatry and the medicine services) arent very good at their jobs and are doing things out of order.

With the clozaril guy, what did the chest film show?

With the macrocytic anemia pt, when did our field become the 'go to' for blood smear/macrocytic anemia questions?

And yes, it can hurt to question them and do physical exams on your C/L patients. How would you like it if your on inpatient psych and you consult medicine for something. They spend a time doing a mse on the patient and asking them a ton of psychiatric questions...then after they are done they stroll by your workstation and say "yeah we'll put him on 20 units of 70/30. Oh and by the way he's definately hypomanic and it's a not unipolar depression. I'd recommend starting a mood stabilizer as well. Thank me later"......

 

[shan564]

With the clozaril guy, what did the chest film show?

I don't remember now, but I don't think chest films would show anything abnormal in myocarditis.

With the macrocytic anemia pt, when did our field become the 'go to' for blood smear/macrocytic anemia questions?

It's not. Nobody was asking about the anemia... it was very mild, and it didn't really need to be treated, so it didn't concern the IM team. It was only useful as a tool to show that she was an alcohol user.

And yes, it can hurt to question them and do physical exams on your C/L patients. How would you like it if your on inpatient psych and you consult medicine for something. They spend a time doing a mse on the patient and asking them a ton of psychiatric questions...then after they are done they stroll by your workstation and say "yeah we'll put him on 20 units of 70/30. Oh and by the way he's definately hypomanic and it's a not unipolar depression. I'd recommend starting a mood stabilizer as well. Thank me later"......

I'm not talking about changing a diagnosis/treatment for something that's unrelated to your field. If medicine thought that the patient might be depressed because they have hypothyroidism, then I wouldn't mind their input.

I wouldn't expect them to do a full MSE, in the same way that I wouldn't do a full physical exam. But I think that a good IM physician will do a cursory review of a person's neuro/psych status and mention "alert/oriented x 3, cooperative, appropriate behavior."