Psychiatry: Everyone's second favorite specialty?

[Shikima]

Man, I wish some of mine wouldn't show up. Two months into it and I haven't had a single no-show. Aren't those like, supposed to happen?

There's no whining in psychiatry....

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[Armadillos]

To be clear the rounding on 35 inpatients on a weekend isn't standard, was giving an extreme example of coverage that happens in case of acts of God/weather emergencies/etc but pointing out that it can be done for 1 or 2 days in psych with no significant impact on outcome in the long run.

Whereas it literally would be impossible for an intern to do that on medicine without killing people.

 

[splik]

To be clear the rounding on 35 inpatients on a weekend isn't standard, was giving an extreme example of coverage that happens in case of acts of God/weather emergencies/etc but pointing out that it can be done for 1 or 2 days in psych with no significant impact on outcome in the long run.

Whereas it literally would be impossible for an intern to do that on medicine without killing people.

I provided coverage to over 70 patients as standard, and on occasion well over 100 patients as a medical house officer. It was not good care but it is certainly possible. also medicine often has more stable patients awaiting placement than does psychiatry.

 

[Armadillos]

Holy crap I do not envy having to cross cover 100 medicine patients, I thought covering 40 was bad enough seemed my pager never, ever stopped buzzing and there was always a couple patients trying to end up in the unit.

 

[DD214_DOC]

There's no whining in psychiatry....

Wait, isn't that all this field is?

 

[Blitz2006]

Holy crap I do not envy having to cross cover 100 medicine patients, I thought covering 40 was bad enough seemed my pager never, ever stopped buzzing and there was always a couple patients trying to end up in the unit.

You wouldn't enjoy being a medicine intern in the UK then 😛. Quite common to cover 100 medicine patients on the weekend and on night float.

 

[Blitz2006]

Honestly as much as I love my outpatient job, if a med student had to follow me around for a month, they'd probably be bored out of their minds. So much context is lost when you're not observing a patient over time in outpatient psych.

I'm also kind of wondering what kind of crap training these medical students are getting if that's all they're seeing for inpatient. For the love of god kids, don't let them send you to a nonacademic place for your psych month!.

I respectfully disagree. My experience in outpatient (not just psych, but even other specialities like derm) as a med student was awesome. The attending let me see the patient my own, come up with a management plan on my own, then I would present and discuss the gameplan with him/her. I actually felt like a doctor and was able to contribute to academic discussion. I remember I would discuss psychopharm in detail with my attending, asking her why checking VPA level at a certain day, why was it necessary to order CBC for a person on Depakote, etc.

As opposed to inpatient as a med student, where I was just running around the floors all day doing stupid scutwork (or even worse, running to get batteries for my intern's pager!) and then mindlessly writing progress notes to help the resident out. I'm on inpatient psych now, and my med student (as much as I try to get her involved) looks terribly bored at times.

 

[Blitz2006]

Psych is a completely different paradigm. We don't have very many unique conditions with unique treatments. We have depressed, psychotic, anxious, or manic. The complexity lies in the multiple etiologies and the environmental and interpersonal interaction with the illness. If you ignore the truly complex aspects of psych, then it is incredibly simple. It's just not good practice.

Bingo, you nailed it.

This is what I love about psych, is the MICROMANAGEMENT of mental health due to the complexity. My medicine friends always talk about how they know so much more than us. But they don't understand is the complexity of an illness, and how even tiny changes in medication can make a difference (like going from 1mg ativan BID to 0.5mg BID). I find their knowledge to be obviously very widespread, but not so in dept. Most good psychiatrists can you tell you in the ins and outs of every psych drug (side effects, half life, risk of SJS in lamictal stats, etc), whereas in other specialities I don't find that same level of depth of knowledge (just my 2 cents/observation).

 

[Blitz2006]

You know, I think higher end, more detailed thinking is required for inpatient work. It might not be happening in some inpatient settings, but inpatient work if done well isn't easy. From what I'm reading on this board, hospitals and psychiatrists who think seeing 10+ patients in half a day or seeing 35 patients in a weekend is reasonable are creating this inadequate treatment norm for inpatient care. I'm actually enjoying my current inpatient job more than my outpatient job because it gives me time to think about my patients in more detail. I guess I'm lucky to live in a community where these super high volume inpatient practices are not the norm. It wasn't the norm in my training and hasn't been the norm in my post-training work either. Sure, we have this push to do a lot of treatment in the outpatient setting, but that doesn't mean inpatient work is all about placement.

Interesting. I'm very Pro-outpatient, but one aspect of inpatient I do like is the initial admission, Day 1 part. I enjoy cleaning up a lot of the "mess" these patients come in on from the outpatient world, like being on 3 mood stabilizers for no reason, ridiculous combinations of meds, etc. But I just find Day 2-10 a bit slow, monitoring patient on the unit and waiting for placement (aka, liasing with social workers).

But I'm just a humble resident, so maybe its different as an attending.

 

[technopoly]

I respectfully disagree. My experience in outpatient (not just psych, but even other specialities like derm) as a med student was awesome. The attending let me see the patient my own, come up with a management plan on my own, then I would present and discuss the gameplan with him/her. I actually felt like a doctor and was able to contribute to academic discussion..

Having done two outpatient psych electives, I would say one experience I had was like this while the other was completely a shadowing experience during which I annoyed my attendings for reading suggestions related to their respective interests in the field. In the former, I almost always did initial evaluations and my assessment and management suggestions were taken seriously or torn apart in detail. Likewise, on inpatient at my hospital I was usually doing a lot of data gathering or checking in with my patients on my own. I don't think either experience can be broadly generalized- like almost anything else. Except politics, of course.

 

[Shikima]

Bingo, you nailed it.

This is what I love about psych, is the MICROMANAGEMENT of mental health due to the complexity. My medicine friends always talk about how they know so much more than us. But they don't understand is the complexity of an illness, and how even tiny changes in medication can make a difference (like going from 1mg ativan BID to 0.5mg BID). I find their knowledge to be obviously very widespread, but not so in dept. Most good psychiatrists can you tell you in the ins and outs of every psych drug (side effects, half life, risk of SJS in lamictal stats, etc), whereas in other specialities I don't find that same level of depth of knowledge (just my 2 cents/observation).

I don't know about you, but I micromanage nothing. Waste of time and energy, and it doesn't reimburse.

 

[Shikima]

I provided coverage to over 70 patients as standard, and on occasion well over 100 patients as a medical house officer. It was not good care but it is certainly possible. also medicine often has more stable patients awaiting placement than does psychiatry.

Ditto.

UHS has you round on 80+ on both days for a weekend.

 

[WingedOx]

also medicine often has more stable patients awaiting placement than does psychiatry.

I thought the purpose of the psych unit was to be a holding area so stable patients awaiting placement could leave the medicine floors...

...at least that's what every PG-2 medicine resident tries to convince us about once per week.

 

[aspiringdoc09]

Man, I wish some of mine wouldn't show up. Two months into it and I haven't had a single no-show. Aren't those like, supposed to happen?

Idk, I rather be busier than not but I'm still a student so what do I know. Lol.

 

[DD214_DOC]

Idk, I rather be busier than not but I'm still a student so what do I know. Lol.

Just wait. As an attending, you will have a thousand other non-clinical things on your plate/schedule. It would be nice to be able to get some of that stuff done during the day.

 

[NontradCA]

On the whole 'real Doctor' subject, I must admit this is an objection to Psychiatry I don't really get. I mean you still do however many years of medical training it is in the US, and the couple of times I've become ill in a session with a presyncope episode it's not exactly like my Psychiatrist has just sat there and gone 'OMG I've completely forgotten 6-8 years of medical training and now I have no idea what to do'. Just because you're not whipping out a stethoscope every 5 minutes doesn't make you 'not a real Doctor'.

I'm only a 2nd year student, but it's more than just the stethoscope. It's coming up with a ddx from the distinct pathophys that we're taught. There's also the interpretation of lab values, images and monitors. I think med students don't like the grey area. We're in general, task oriented type of people. By our nature, we want to know everything to complete it, and psych leaves a lot to be desired for us. That's my opinion.

 

[smalltownpsych]

I'm only a 2nd year student, but it's more than just the stethoscope. It's coming up with a ddx from the distinct pathophys that we're taught. There's also the interpretation of lab values, images and monitors. I think med students don't like the grey area. We're in general, task oriented type of people. By our nature, we want to know everything to complete it, and psych leaves a lot to be desired for us. That's my opinion.

You might want to work more on being comfortable with that grey area because you might see more and more of it as you progress in your training unless you narrow your focus to exclude some critical variables that are more difficult to measure. A good doctor should be able to tolerate a certain amount of ambiguity. On the other hand, the research on this tends to suggest that ambiguity tolerance plays a role in the selection of specialty as some areas of medicine are more concrete than others. Here is an abstract of a study related to this. http://www.sciencedirect.com/science/article/pii/027795369090098D
Here is an article proposing that management of ambiguity should be a factor in assessing competence.
http://acmd615.pbworks.com/w/file/fetch/46353210/epstein_JAMA.pdf

 

[aspiringdoc09]

I'm only a 2nd year student, but it's more than just the stethoscope. It's coming up with a ddx from the distinct pathophys that we're taught. There's also the interpretation of lab values, images and monitors. I think med students don't like the grey area. We're in general, task oriented type of people. By our nature, we want to know everything to complete it, and psych leaves a lot to be desired for us. That's my opinion.

I think that's the whole Type A personality thing. I've always been one to accept the fact I can't control every single thing.

Just wait. As an attending, you will have a thousand other non-clinical things on your plate/schedule. It would be nice to be able to get some of that stuff done during the day.

I hear ya. I know I will be feeling the same way. Is it easier to do the non clinical stuff now with he EMR system vs paper notes or more of a headache?

 

[DD214_DOC]

I think that's the whole Type A personality thing. I've always been one to accept the fact I can't control every single thing.



I hear ya. I know I will be feeling the same way. Is it easier to do the non clinical stuff now with he EMR system vs paper notes or more of a headache?

Depends on the EMR system; some are much better than others. Technology is (almost) always better, and being computer savvy can pay dividends. I never realized MS Word and Excel were able to be programmed using visual basic extensions until a month ago. This has made life much easier, and I continue to refine things and automate what I can.

But beyond charting, you will also be tasked to hospital committees, peer reviews, and blah blah blah

 

[aspiringdoc09]

Depends on the EMR system; some are much better than others. Technology is (almost) always better, and being computer savvy can pay dividends. I never realized MS Word and Excel were able to be programmed using visual basic extensions until a month ago. This has made life much easier, and I continue to refine things and automate what I can.

But beyond charting, you will also be tasked to hospital committees, peer reviews, and blah blah blah

I guess it is administrative work galore. Lol. Not looking forward to that. Why can't it ever just be about the patients hahahaha!

 

[Dharma]

I think med students don't like the grey area. We're in general, task oriented type of people. By our nature, we want to know everything to complete it, and psych leaves a lot to be desired for us. That's my opinion.

That same grey zone is something that attracts many to psych. AI can handle the clear cut algorithmic work.

 

[NontradCA]

You might want to work more on being comfortable with that grey area because you might see more and more of it as you progress in your training unless you narrow your focus to exclude some critical variables that are more difficult to measure. A good doctor should be able to tolerate a certain amount of ambiguity. On the other hand, the research on this tends to suggest that ambiguity tolerance plays a role in the selection of specialty as some areas of medicine are more concrete than others. Here is an abstract of a study related to this. http://www.sciencedirect.com/science/article/pii/027795369090098D
Here is an article proposing that management of ambiguity should be a factor in assessing competence.
http://acmd615.pbworks.com/w/file/fetch/46353210/epstein_JAMA.pdf

So that backs up my opinion

 

[NontradCA]

That same grey zone is something that attracts many to psych. AI can handle the clear cut algorithmic work.

One thing that worries me is that this ambiguity opens doors for others to practice shotty medicine. From my limited understanding there are a not so insignificant number of incompetent psychiatrists. Someone mentioned needing more adherence to our evidence based treatments, yet psych is among the lowest if not the lowest among specialties that are sued. Also, how can psychiatrists defend themselves against encroachment with all the ambiguity? As someone interested in psych, this worries me.

 

[smalltownpsych]

One thing that worries me is that this ambiguity opens doors for others to practice shotty medicine. From my limited understanding there are a not so insignificant number of incompetent psychiatrists. Someone mentioned needing more adherence to our evidence based treatments, yet psych is among the lowest if not the lowest among specialties that are sued. Also, how can psychiatrists defend themselves against encroachment with all the ambiguity? As someone interested in psych, this worries me.

The more difficult and complex the problems, the greater the expertise needed to address it would be how I would argue against encroachment. Reducing the treatment of mental illness to disorder A = treatment B is what opens the door for encroachment. Our PMHNP knows all of the psychotropic medications and what they are indicated for, but has no better than a layman's understanding of the DSM and psychotherapeutic conceptualizing. A psychiatrist should have a bit more knowledge of the drugs and medicine than an NP, but also 4 years of learning how to hone their conceptual skills and maximize the efficacy of their interventions both through communication and medication. In my mind, that would set you apart and helps to shield against the encroachment.

As far as shoddy practices, I have seen shoddy practices from the doctors, true; but the shoddiest has been from midlevels with online degrees and they are flooding the market.

 

[Blitz2006]

I think that's the whole Type A personality thing. I've always been one to accept the fact I can't control every single thing.



I hear ya. I know I will be feeling the same way. Is it easier to do the non clinical stuff now with he EMR system vs paper notes or more of a headache?

It's funny because that's one of the reasons i chose psych, due to my type A.

I love the fact that I can spend one morning doing ECT/inpatient, than in the afternoon do clinic. Then the next day do ER, etc. The flexibility is awesome, and the potential to work 7 days a week is there if you want it.

Surgery on the other hand, I found I spent most of my time waiting for scans to be reported, waiting for anestheisa and then when operating a lot of the time was BS like lysing adhesions, etc.

I find psych to be super efficient and variable speciality, which I find to be academically stimulating (I don't like repetition like a lot of specialities)

 

[Leo Aquarius]

One thing that worries me is that this ambiguity opens doors for others to practice shotty medicine. From my limited understanding there are a not so insignificant number of incompetent psychiatrists. Someone mentioned needing more adherence to our evidence based treatments, yet psych is among the lowest if not the lowest among specialties that are sued. Also, how can psychiatrists defend themselves against encroachment with all the ambiguity? As someone interested in psych, this worries me.

Good questions. Psychiatrists don't have to defend against encroachment. Here's why. The bulk of the proverbial pyramid is made up of all the primary care doctors, midlevels, and psychologists, and inadequate psychiatrists who are trying to treat mental health disorders, but for this reason or that they cannot achieve the treatment efficacy needed (mental health is difficult to treat). So, the millions of people with semi-treated disorders say "I'm fed up" and ask their doctors and friends for a referral to a good psychiatrist. Let me crunch some sobering numbers for us:

- Approximately 1 in 5 adults in the U.S.—43.8 million, or 18.5%—experiences mental illness in a given year
- Psychiatrists number around 38,000 in the USA, of these let's assume 25% are considered really good
- The land area of the USA is 3.8 million sq miles

That's 1 psychiatrist per 1000 square miles, or 1 really good psychiatrist per 4000 square miles (larger than the area of Delaware, almost the size of Connecticut)
That's 1 psychiatrist per 1153 mentally ill people, or 1 really good psychiatrist per 4612 people with a mental illness

That's why.

 

[Doctor Bagel]

Interesting. I'm very Pro-outpatient, but one aspect of inpatient I do like is the initial admission, Day 1 part. I enjoy cleaning up a lot of the "mess" these patients come in on from the outpatient world, like being on 3 mood stabilizers for no reason, ridiculous combinations of meds, etc. But I just find Day 2-10 a bit slow, monitoring patient on the unit and waiting for placement (aka, liasing with social workers).

But I'm just a humble resident, so maybe its different as an attending.

Everything is better when you're not a resident. I like outpatient where you can do therapy and work with people over time. I'm not a fan of med management mills, which I think is what a lot of outpatient is these days if you're employed. Other inpatient advantages -- way less isolation and more opportunities for case discussions, and I never have to do concurrent charting which I think is evil. No jobs are perfect, but if you're sticking with employed work, I don't get where inpatient is that much worse than outpatient. Ok, well aside from the call, but you also get paid for that, and it's still better than being a resident.

 

[Ceke2002]

I'm only a 2nd year student, but it's more than just the stethoscope. It's coming up with a ddx from the distinct pathophys that we're taught. There's also the interpretation of lab values, images and monitors. I think med students don't like the grey area. We're in general, task oriented type of people. By our nature, we want to know everything to complete it, and psych leaves a lot to be desired for us. That's my opinion.

I guess I see things a bit differently. Medicine for me is more about the fascination with this thing called the human body, and the human condition as an extension, that we don't know everything about so let's get in there and study it. I don't really care about everything being complete and fitting into place, I just want to expand my knowledge. That's just me though.

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And in answer to the OP's original question, just speaking from a personal viewpoint (from one who isn't yet a med student but who is hoping to be in a few years time) Psychiatry would have been my second choice, only because Emergency Medicine was my first. EM just seemed like it would have suited my personality, and the type of environment I like to work in, more than any other specialty - Psychiatry, on the other hand, whilst also very appealing did kind of make me think 'I don't want to be that cliche image of the Psych patient who becomes a Psychiatrist themselves' (that's totally my own bias towards myself, not aiming that at anyone other than me), as well as not being sure if I could handle the mental/emotional load of the work (I sort picture myself working with a never ending stream of me and then wanting to punch things out of sheer frustration). That being said now that I have been forced to realise that I am simply not physically capable of doing Emergency Medicine, my second choice is now my first. IF I get into my undergrad, to get into medicine post grad, complete my 2 years as an RMO and get accepted into RANZCP's fellowship program, provided I'm studying full time without any deferred years, I will be 58 when I'm fully qualified. Hopefully couches will be back in fashion by then...for me, not the patient. 😉😛