Psychiatry as a Stressful Specialty

[phanto]

Many news sources in the past have listed Psychiatry as one of the more stressful specialties. These sources cite that listening to personal problems from the most vulnerable members of our society drains the batteries of many mental health professionals. How does this coincide with your own personal experiences?

Some of the same studies have also found that many Psychiatrists have their own personal histories with depression, which increases their vulnerability to stressors. Do you agree with this idea? Does it match your own life experience?

All opinions are welcome, especially residents and attendings who wish to give input.

---

Members don't see this ad.

 

[loveoforganic]

<=Premed disclaimer

1) A lot of the stories of the patients in inpatient hospitals are just heartbreaking (particularly for the kids). Going hand in hand with that is anger at people that put the patients in the situation they're in (assuming someone did). During my brief time volunteering in the hospital, these were definitely draining aspects.

2) People are attracted to what has affected them. Bad heart -> cardiology, bad brain -> psychiatry. That's an oversimplification and isn't applicable to everyone obviously. Building on that, depression (and other disorders) can tend to relapse under stress. I'm not sure if that's what you were asking.

 

[masterofmonkeys]

I'm hoping to do pediatric pain, children with medical comorbidites, and somatoform disorders.

From the opportunities I've had to work on this (on gen peds and peds neuro, everyone gratefully threw these patients at me), it was stressful, intense, discouraging, and demanding. No doubt, made more so by my own experience as a child with significant amount of pain due to neuromusculoskeletal issues.

Needless to say, I am hoping to avoid attempting to swallow my own gun at some point during my life.

 

[Sneezing]

I didn't decide to do psych because of a past mental illness. I'm going to into psych because it is awesome. Is it stressful? I hope so. If it weren't it would be more of a reason to let other people do it. Practicing medicine is supposed to be stressful.

And now for the old cliche... No pain, no gain. The stress helps make it worth it.

 

[whopper]

I've gone through growing pains on what I find stressful. I used to find cluster B patients very stressful. Now I don't. It was an evolution of a few years and learning more about DBT.

The two biggest things I'm finding stressful now is just the bureaucracy of working in specific institutions, and having a patient who is in that grey area of "maybe dangerous, maybe not" in outpatient. It's holding the wolf by the ears. You don't want to let go, but you don't want to hold on either. Happens once in awhile in outpatient.

 

[Shikima]

What if find most stressful during residency is the high volume of patients and not able to dedicate a reasonable amount of time (at times). During the times when I need to do a proper interview to really figure out what is going on, both pagers (call and personal) are going off every other minute with the telephone ringing from the inpatient service.

Also, I find that to do this line of work, one must be rested to deal with what it being thrown at you. Their lives are a wreck, drugs and ETOH compound the problems, poor coping skills or just behaviorally challenged. Not to mention ancillary staff who are demanding of you too at the the same time.

Bottom line, if you like a challenge, this is it. But we often forget to take care of ourselves too.

 

[phanto]

Thanks for your opinions so far.

 

[Regnvejr]

Not a lot of stress. More frustration with patients needs not being met by social services of various types, frustration with prior authorization and such. But the patients, that's the bright spot. Some you help, some don't get better even when you work hard, and some you are happy if they didn't get worse by next time you see them. But overall, they end up with a little bit more control over their own life than before they met you. That's not stressful, that's awesome.

 

[babel]

I don't see why psych would be considered a particularly stressful specialty (and I can't say that I have heard of any reports along those lines). Of course, it might be stressful for the people who are not well suited for it - I've had many classmates tell me that they find it fascinating, but too depressing/overwhelming etc. to do for the rest of their lives - but for those who make the right choice going into the field, I agree with Regnvejr - it's more likely to be awesome.

 

[whopper]

Somewhat adding to what I said above, but a different situation...

I mentioned letting a person go from the office who you aren't certain is a danger to him/herself or others.

E.g. an eating disorder patient who keeps mentioning that she's going to vomit when she goes home and her hair is falling out. Is her potassium level safe? I can't tell in the office. If I send her to the ER, the ER doc would most likely get upset and just discharge her.

But in forensics, I'm sometimes asked to evaluate to see if someone is safe to be discharged in the community.

What do you do if you have a sex-offender (past charge rape) in a forensic unit where you can't exactly peg it down? All their behavior is stable in the hospital, but you're not certain if they are a perpetrator of predatory violence (a type of violence where one is far more likely not to show signs of anger before an attack). Further, you are not certain if they will stay compliant on their meds?

But the person has been find on a psych unit for a year.

That's certainly a situation where the job gets tough.

I just recommended a guy be discharged a few weeks ago that I am convinced will start stalking someone again. Problem here is I don't think he's going to stalk the person due to mental illness. We can't keep people committed if we think they're going to break the law, even harm someone, if it's not due to mental illness.

 

[Sneezing]

I don't see why psych would be considered a particularly stressful specialty (and I can't say that I have heard of any reports along those lines). Of course, it might be stressful for the people who are not well suited for it - I've had many classmates tell me that they find it fascinating, but too depressing/overwhelming etc. to do for the rest of their lives - but for those who make the right choice going into the field, I agree with Regnvejr - it's more likely to be awesome.

Potentially at any moment you could be attacked. So you are constantly at a state of hyperawareness. You are the dumping ground for all the nasty things happen to people. As internist or surgeon you don't care about the social history of a patient except if they have an addiction or insurance. There is also more legal interface. Patients saying they will kill the president or john doe down the street so now you have the duty to inform. Suicidal patients - did you risk stratify them appropriately? Patients accusing staff of sexual assault. The stressors are different then other fields but quite real.

 

[Call Me Ishmael]

As someone interested in it, in what ways would C&A be more/less stressful than general psych?

 

[whopper]

Few of the psychotropics out there have an FDA approval for treating children. Several parents, guardians, and other entities in charge of children may inappropriately want them medicated (e.g. they just want the child to shut-up; "Doctor, my baby cried yesterday, can't you give me something to prevent her from crying?") When you interview the child, it's hard to get a picture of what's going on because children don't often offer as much information as adults, and when you try to get collateral information from adults, they often have agendas not in the best interests of children.

 

[babel]

The stressors are different then other fields but quite real.

I agree with this. Certainly there are things that are stressful about the practice of psychiatry that are not present in other fields of medicine. I just don't think that if one were to stratify the specialties by the amount of stress that psychiatry would be uniquely stressful.

 

[J ROD]

I dont think Psy is "stressful" in terms of having to do this or that right that second or doing a procedure.....

I think "stressful" is more EM, Surgery, etc.


Psy to me is more draining and emotionally involving....

I think is hard but in a very different way than most specialties.

 

[Sneezing]

I dont think Psy is "stressful" in terms of having to do this or that right that second or doing a procedure.....

I think "stressful" is more EM, Surgery, etc.


Psy to me is more draining and emotionally involving....

I think is hard but in a very different way than most specialties.

"more draining and emotionally involving" that's what stress is. Same thing. Synonym. Tomato Tomatoe.

 

[whopper]

What some people find annoying, others don't.

My wife loves treating cluster B patients. I used to hate treating them. My wife has turned me onto treating more and more because she is mastering DBT. I'm going to attend a DBT conference because some of the things she's taught me have had some very beneficial effects with my cluster B patients.

Right now, a new phenomenon I'm encountering now that's ticking me off are patients asking me to fill out a disability form, and most of the things they judge wants to know, I have no idea.

E.g., I've only seen the patient twice in outpatient and it's asking me to describe the patient's ability to do minor labor (e.g. pick up objects, carry them). I have no idea.

Another problem is some of my patients I do believe deserve disability--temporarily. E.g. maybe 2-3 months while I get their panic attacks under control. Based on experience and empirical data, a large subset of those patients, even after they've been stabilized, will try to stay on disability for the rest of their lives. The problem here is with several psychiatric disorders such as panic disorder, your ability to gauge the panic attacks is only on what the person tells you. In outpatient, I have no idea if the person's panic attacks are continuing for real. I can only go based on what the patient tells me.

The the judge asks me if the person is having panic attacks, and I can only answer on what the person tells me. Judges don't want to hear that. So what am I supposed to do? Have someone follow them 24/7 with video? You tell me Judge!

 

[J ROD]

"more draining and emotionally involving" that's what stress is. Same thing. Synonym. Tomato Tomatoe.

not to me.....

stress is fast-paced, got to do it now.

draining is something that just grinds on you....


Basically, stress gets the heart going, and draining does not.

 

[kugel]

not to me.....

stress is fast-paced, got to do it now.

draining is something that just grinds on you....


Basically, stress gets the heart going, and draining does not.

These are incredibly important things to know about yourself in regards to choosing a career path, specialty, practice setting.
Knowing what stresses YOU is very helpful.
I wish every med student and resident would periodically (1x/year?) sit down and take a hard look at what kind of situations, practice settings, patient types, colleagues they find rewarding vs stressful - regardless of the field of medicine.

 

[Rabbit Hole]

Many news sources in the past have listed Psychiatry as one of the more stressful specialties. These sources cite that listening to personal problems from the most vulnerable members of our society drains the batteries of many mental health professionals. How does this coincide with your own personal experiences?

Some of the same studies have also found that many Psychiatrists have their own personal histories with depression, which increases their vulnerability to stressors. Do you agree with this idea? Does it match your own life experience?

All opinions are welcome, especially residents and attendings who wish to give input.

I just stumbled across this topic.
Would you mind listing these citations/sources so that we can take a look at them. It would really help to put this in context - there is a big difference between opinions based on misconceptions vs. actual evidence-based studies.

 

[Baller MD]

Do listening to patient's problems everyday ever become too much of a burden?

 

[thepoopologist]

Do listening to patient's problems everyday ever become too much of a burden?

Yes, but only when it is a type of patient I do not have as much experience with or the adequate skills to deal with. Learning is sometimes a painful experience and tends to drag me down especially when I can't deal with the countertransference issues. It's a different story when your skillset is there. Listening to someone spill there guts out doesn't constitute therapy much less the whole of psychiatry. That's the 1st step. You have to place their commentary within the framework of where they are/where they are supposed to be socially and cognitively. You think about personality structure. You think about the defenses that protect that structure. You wonder where the acute deficit in emotion/thinking is , where the chronic issues are. Any other layers? What should be considered normal? What should be considered abnormal? How functional are they now compared to their norm? Also, who do they have around them socially? Who did they have around them? How did these interactions make them the person they are today (lots of reading here)? Any developmental issues? What about medical issues, and if there are any how are they contributing, and can I handle it on my own? Substance abuse? Emotional or physical traumas? What do I fix first? Will a pill do or is therapy warranted (there is a lot to consider here considering the variable effectiveness of each based on a lot of literature you have to read, further complicated by the pt's own individual experiences, motivation, insight, judgement)? Which pill? Which therapy? If the first trial doesn't work, then what doesn't work, and what should I do next? Should other specialists be involved? DSM criteria (constantly reassessed)? I probably left out a lot of crap. But you get the picture. There is a lot to think about. Its basically profiling someone in their entirety, prioritizing their problems/issues, and figuring out how best to help them. Or deciding if they are really problems at all. There is a lot of gray area in how to approach a lot of this.

I once met someone who diagnosed bipolar disorder by opening up the DSM and going down the list of symptoms. When the patient met enough symptoms, they were diagnosed with bipolar disorder and put on a mood stabilizer. Whether the answer is right or wrong, the approach is embarrassingly simplistic, doesn't take into consideration the several other possibilities for each one of those symptoms, or for the overall presentation, and potentially puts them on a mood stabilizer that they don't need. Or the therapist that lets someone vent month in and month out, it does nothing except make the therapist a regularly scheduled whipping post. One isn't psychiatry and the other isn't therapy

 

[Nasrudin]

Somewhat adding to what I said above, but a different situation...

I mentioned letting a person go from the office who you aren't certain is a danger to him/herself or others.

E.g. an eating disorder patient who keeps mentioning that she's going to vomit when she goes home and her hair is falling out. Is her potassium level safe? I can't tell in the office. If I send her to the ER, the ER doc would most likely get upset and just discharge her.

But in forensics, I'm sometimes asked to evaluate to see if someone is safe to be discharged in the community.

What do you do if you have a sex-offender (past charge rape) in a forensic unit where you can't exactly peg it down? All their behavior is stable in the hospital, but you're not certain if they are a perpetrator of predatory violence (a type of violence where one is far more likely not to show signs of anger before an attack). Further, you are not certain if they will stay compliant on their meds?

But the person has been find on a psych unit for a year.

That's certainly a situation where the job gets tough.

I just recommended a guy be discharged a few weeks ago that I am convinced will start stalking someone again. Problem here is I don't think he's going to stalk the person due to mental illness. We can't keep people committed if we think they're going to break the law, even harm someone, if it's not due to mental illness.

Thanks for these examples. They're like a case based textbook.

 

[Shikima]

What some people find annoying, others don't.

My wife loves treating cluster B patients. I used to hate treating them. My wife has turned me onto treating more and more because she is mastering DBT. I'm going to attend a DBT conference because some of the things she's taught me have had some very beneficial effects with my cluster B patients.

Right now, a new phenomenon I'm encountering now that's ticking me off are patients asking me to fill out a disability form, and most of the things they judge wants to know, I have no idea.

E.g., I've only seen the patient twice in outpatient and it's asking me to describe the patient's ability to do minor labor (e.g. pick up objects, carry them). I have no idea.

Another problem is some of my patients I do believe deserve disability--temporarily. E.g. maybe 2-3 months while I get their panic attacks under control. Based on experience and empirical data, a large subset of those patients, even after they've been stabilized, will try to stay on disability for the rest of their lives. The problem here is with several psychiatric disorders such as panic disorder, your ability to gauge the panic attacks is only on what the person tells you. In outpatient, I have no idea if the person's panic attacks are continuing for real. I can only go based on what the patient tells me.

The the judge asks me if the person is having panic attacks, and I can only answer on what the person tells me. Judges don't want to hear that. So what am I supposed to do? Have someone follow them 24/7 with video? You tell me Judge!

I get a lot of these in my clinic too. And for the most part, I also agree. However, I do offer the caveat that I cannot evaluate their physical functioning and can only render an opinion regarding their mental/emotional health. Their physical difficulties will need to be evaluated by their PCP. This puts the need to collect information in the Pt's lap and I'm not struggling to figure a creative way in completing the form so the judge will be pleased.

 

[Baller MD]

I once met someone who diagnosed bipolar disorder by opening up the DSM and going down the list of symptoms. When the patient met enough symptoms, they were diagnosed with bipolar disorder and put on a mood stabilizer. Whether the answer is right or wrong, the approach is embarrassingly simplistic, doesn't take into consideration the several other possibilities for each one of those symptoms, or for the overall presentation, and potentially puts them on a mood stabilizer that they don't need. Or the therapist that lets someone vent month in and month out, it does nothing except make the therapist a regularly scheduled whipping post. One isn't psychiatry and the other isn't therapy

Is it legally okay to do that? I think I tend to see junior residents do that more often than the experienced psychiatrists. Granted, I do it too as a med student eg sigecaps when diagnosing depression (bc what else am I supposed to do?).

 

[vistaril]

I once met someone who diagnosed bipolar disorder by opening up the DSM and going down the list of symptoms. When the patient met enough symptoms, they were diagnosed with bipolar disorder and put on a mood stabilizer.

well on the bright side, at least that's an upgrade over how many people are dxed with Bipolar and put on Bipolar meds. At least in this case the person doing the dx appeared to care about attempting to make a dx(even if the spirit is wrong)

 

[nitemagi]

Is it legally okay to do that? I think I tend to see junior residents do that more often than the experienced psychiatrists. Granted, I do it too as a med student eg sigecaps when diagnosing depression (bc what else am I supposed to do?).

Understanding the mind/brain is like understanding physics. There's iterations to the understanding. I did a blog post on this some time ago.

 

[Frazier]

Understanding the mind/brain is like understanding physics. There's iterations to the understanding. I did a blog post on this some time ago.

Cool site and blog. 👍
You look like you could be an actor over there in LA.

 

[hamstergang]

Understanding the mind/brain is like understanding physics. There's iterations to the understanding. I did a blog post on this some time ago.

Reminds me of Asimov's The Relativity of Wrong: http://chem.tufts.edu/answersinscience/relativityofwrong.htm

 

[nitemagi]

Cool site and blog. 👍
You look like you could be an actor over there in LA.

Hah!

 

[smalltownpsych]

Do listening to patient's problems everyday ever become too much of a burden?

Isn't that what all doctors do? Many of the other docs I work with still have to hear or confront patients emotional/social/psychological problems, they just have less tools to help and some can get pretty jaded or burnt-out, as well. One of the main components of a psychologist's set of competencies is effective self-care to help keep us functioning optimally. To me stress is not the issue as much as burn-out or compassion fatigue. As other posters have said, stress is part of the game, being over capacity is the problem. Now that I mention it, for a lot of my patients, that is the problem as well.

 

[digitlnoize]

Many news sources in the past have listed Psychiatry as one of the more stressful specialties. These sources cite that listening to personal problems from the most vulnerable members of our society drains the batteries of many mental health professionals. How does this coincide with your own personal experiences?

Some of the same studies have also found that many Psychiatrists have their own personal histories with depression, which increases their vulnerability to stressors. Do you agree with this idea? Does it match your own life experience?

All opinions are welcome, especially residents and attendings who wish to give input.

I would say that it's not that stressful. Take a look at the Medscape Physician Compensation Report from 2014 (slide 10):

http://www.medscape.com/features/slideshow/compensation/2014/psychiatry#10

This ranks psychiatry a #2 in career satisfaction, with ~60% saying they would do it again. Neurology by comparison is in the mid-40%'s, near the bottom.

Yes, we hear some tough stories. Yes, there are times during residency when I'm stressed out. Still, its FAR less stressful than any other job I've ever had. I get to spend my day talking to people and trying to help them the best I can. That's pretty awesome.

 

[Psych56]

Understanding the mind/brain is like understanding physics. There's iterations to the understanding. I did a blog post on this some time ago.

Where can I access this blog?

 

[Nasrudin]

Just finished Neurology and medicine and now on psych. Even with struggle of being a new intern in a functioning machine that has to begrudgingly slow down for you to fit into your part of it, I don't find it as stressful as medicine. And by extension many of the other specialties that I can extrapolate a comparison to.

This could be to a large degree related to the type of mind relating to the type of work. And of course busy call is stressful no matter what specialty.

But it's never a mind numbing grind while skating precariously on the thin ice of life/death separated by a weary oversight of this or that detail. That may sound dramatic to well supported, staffed, supervised medicine programs but it's only matter of fact for my experience. Which was that the only difference between me and the intern taking care of Libby Zion was luck.

So no. Now that I'm getting used to handling agitated psychotic patients. It's not stressful by and large. And I find this gives me a great deal more independence to manage my own work. I can pick and choose when to talk with this family, call for that collateral, meet with that patient, etc according to a natural flow of me and the environment. Which is a huge stress relief by comparison.

 

[Nasrudin]

Where can I access this blog?

Click blog in his signature.