Psychiatry: Everyone's second favorite specialty?

[JDoc9]

Okay, maybe not "everyone", but more often than any other specialty, I always hear physicians/prospective physicians say "I was thinking about going into psych, but xyz happened". What do you think this is caused by? The internal insecurity of not being looked at as a "real doctor" by friends, family, medical colleagues, etc? The pay (which is not a very legitimate reason if said person has done his/her research regarding pay in psychiatry)? What do you guys think can be done to increase interest in psychiatry among medical students and make it go from "I almost chose psychiatry" to "I did choose psychiatry"?

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[MacDonaldTriad]

We need to get students out of inpatient psychiatry and show them something more representative of what we do.

Med students are very susceptible to charismatic mentors. We just need to prioritize teaching more and have departments value teaching.

 

[technopoly]

The psychiatry related lectures at my school were a mixture of neuroanatomy and physiology as well as pharmacology that gave the impression that the mechanism of psychiatric treatments involved a lot of handwaving and "Well, we think it works this way."

I think this can lead some students to mistake psychiatry as a"soft science." I wish Stahl's psychopharmacology could be incorporated a bit into the curriculum, or that cutting edge research in neuropsychiatry were discussed in more detail to demonstrate that this is not the case.

 

[Doctor Bagel]

The psychiatry related lectures at my school were a mixture of neuroanatomy and physiology as well as pharmacology that gave the impression that the mechanism of psychiatric treatments involved a lot of handwaving and "Well, we think it works this way."

I think this can lead some students to mistake psychiatry as a"soft science." I wish Stahl's psychopharmacology could be incorporated a bit into the curriculum, or that cutting edge research in neuropsychiatry were discussed in more detail to demonstrate that this is not the case.

I don't know -- there are lots of criticisms of Stahl in that he might overstate what we know. Sometimes the hand-waving is honest.

I do think higher quality basic science lectures are a good thing. My school actually had a fairly detailed human behavior section in our first and second years and historically sent high numbers of people into psychiatry. The school that I did my residency seemed to focus all their (very limited) human behavior curriculum on being a nice person and having empathy -- you can do that in family medicine, too.

 

[medimedimedi]

I think it's the prestige and widespread impression that it's not real medicine issue

 

[sunlioness]

Med students are very susceptible to charismatic mentors. We just need to prioritize teaching more and have departments value teaching.

That's petty much entirely why I initially matched into medicine. No joke.


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[MacDonaldTriad]

I know someone who picked their undergraduate university because he liked the record store across the street. I guess everyone has their personal reasons for being influenced by some things and not others.

 

[notdeadyet]

I don't know -- there are lots of criticisms of Stahl in that he might overstate what we know. Sometimes the hand-waving is honest.

Yikes, I agree with this. A lot of Stahl's stuff falls under what I'd consider pseudo-science (with an industry bent). Talking about prescribing this because of this particular affinity tends to not prove out in studies. He tends to base a lot of his stuff off of studies done by the company's themselves. He delivered a talk during my residency and I wasn't very impressed when he was asked some pointed questions.

I think psychiatry will be a more attractive specialty to medical students when 1) it feels more like an actual field of medicine instead of a standalone thing and 2) we fight the image of our fight being one of futility.

We kill both of those birds with the single stone of evidence-based practice. More research, listening to the research, doing innovative clinical trials, and then actually practicing according to an evidence-base. I think a lot of the clinically-minded academic programs with a good research wing are doing exactly that. It's interesting that there is sometimes a knee-jerk reaction from some of the therapy folks when I toss this out. It's interesting because our evidence-based psychotherapy interventions have some of the best evidence out there for many things.

 

[splik]

I have been involved in exploring recruitment into psychiatry issues in 3 different countries (every country struggles with this). The literature in the US on the issue is very interesting because unlike in other countries psychiatry used to be a popular specialty and then went into decline. Elsewhere psychiatry was always unpopular. The interesting trends are particularly:

1. psychiatrist is at its least popular when it has been most biologically oriented
2. psychiatry was at its most popular when tied to social justice and therapeutic optimism
3. students began to ditch psychiatry for primary care from the 1970s onwards when these specialties appeared to be fighting
4. the prestige issue really only became a significant thing as more Asians started getting into med school. The increase in Asian medical students correlates with the decline in students choosing psychiatry
5. early exposure to psychiatry in the first two years of medical school may impact student's decision making
6. students are less interested in psychiatry after doing their psychiatry clerkship
7. schools with more respected psychiatry departments within their medical school and longer psychiatry clerkships have more students going into psychiatry. Schools like UC Davis, Loma Linda and Yale have been seen as recruiting a significantly higher number of students into psychiatry

 

[Blitz2006]

We need to get students out of inpatient psychiatry and show them something more representative of what we do.

Med students are very susceptible to charismatic mentors. We just need to prioritize teaching more and have departments value teaching.

I've been saying this for years. Medical students for the majority, spend 4-6 weeks of their psych clerkship in a locked, inpatient unit, and walk out thinking thats all we do is admit bipolar/schizophrenia/depression(suicide ideation) and then just monitor for 7-10 days before discharging.

I mean every specialty has med students in outpatient clinic at some point, why not psych?? Students can truly experience a change they can make by following up with a depressed patient that was started on a SSRI 6-8 weeks ago, or put on VPA 1 month ago, and hear from the patient the positive clinical response they had. Plus they can also withness attendings doing psychotherapy..

Medical students have no idea about all the fellowships available to psych. I mean, I know psych residents who have no idea we can potentially do sleep/pain if we really wanted to, or even just do straight ER Psych. So if psych residents are clueless, what hope do we have for med students?

I don't think prestige is much to do with it to be honest. I also don't think our generation really cares about prestigie. If prestige was such a big deal, why is Derm still #1? I find it hard to believe that the general public are enamored by dermatologists and view them as the cream of the crop (like we do in the medical school world, and I'm not trying to insult derm, just making an anecdotal point). If prestige was such a factor, I'm pretty sure neurosurgery would be ROAD x 100 in competitiveness.....

And if prestige is so popular, one of the hottest fields in IM is now hospitalist, medicine residents are shying away from fields like Cardiology because of the brutal lifestyle and declining reimbursements. My friend in Peds also is saying that hospitalist is a hot field with fellowships popping up everywhere. No slam against hospitalists, but I don't think "Hospitalist" is more prestigious than "cardiologist". I mean, I dont even think the general public really knows what a hospitalist is, so I cant believe residents are doing it for prestige.

And its not money, because data shows that we are on par with middle to upper level specialties if you calculate per hour.

This whole "real doctor" nonsense baffles me. Prescribing psych drugs like Lithium and Haldol and Clozaril are far more "powerful" and have serious side effects/ramifications than dumping a statin for cholesterol or norvasc for BP. I mean my opinion is obviously biased, but I feel more pharmacologically challenged when I prescribe/choose a mood stabilizer than referring to an algorithim for BP management (again, no slam against medicine guys, I fully respect their knowledge and clinical skills, just making a point about psych).

and psych being a soft science also baffles me. Again, I am biased because I like neuropsychiatry, but if you give any resident some articles from AJP or Biological Psychiatry, I'm sure they will agree that it is "hardcore" neuroscience. I mean, I"m presenting at journal club this week the recent publication in AJP on schizophrenics, drug naive, in western China who had MRI analysis of their cortices and other neuroanatomical areas. Hardcore neuroradiology that correlates with schzophrenia, and fascinating as well! Are Psychiatrists going to start ordering MRI Brain for every first break psychosis or monitoring of schizophrenia patients? Probably not, but this could be seen in the future, possibly 10-15 years. Just like how DBS for TRD might be the future, Ketamine, etc.



I also think our generation is more open and concerned about mental health, which is why I am unrealistically optimistic about the future of neuroscience/psychiatry.

 

[Jorje286]

It's a combination of factors. Ostracized, maligned or ridiculed patient population + perception that the specialty is detached from science and evidence-based practice. That makes psychiatry not as socially attractive as other specialties. As some have suggested, some psychiatrists/psychologists don't make this look any better, with the whole psychotherapy vs "biological psychiatry" tug of war, which imo is all nonsense. Psychotherapy is rooted in the "biology" as much as pharmacotherapy.

 

[aspiringdoc09]

I know at my school, they split us up b/t inpatient, outpatient, and I think the VA psych but I haven't rotated yet so not sure on this last one. I agree that it would be a good idea to see more than inpatient. I also think it would be a good idea to split the 4-6 weeks or whateve time b/t the sites for a more well-rounded experience. So far I have experienced both through shadowing and have found them to be very different. I prefer inpatient but it is good to see my options when I reach that point in my career. Also, I started the Psych Interest Group at our school and it is difficult to get genuine interest but for the 10 of us who are interested it is great. I tried to using a theme to bring in speakers from subspecialities like forensic psych or something that is rare to academic centers that students are use to interacting with during classes. I'll have to find a ER psych doctor. According to my classmates who have an initial interest in it and neurology, they feel that psych isn't 1) a hard science, 2) has too much uncertainty in the field as far as diagnoses are concerned [lack of evidence argument], and 3) the classes, at least at our school, were crap. We repeated our first year class doing second year with a few additions and shelf exam. There was no added effort. Our psych department and curriculum can definitely be revamped, which we have a new chair, so it is changing for all the classes following. The quality of teaching was awful too. I definitely agree with having charismatic people and also good mentors.

I think soon enough people will figure out this field is a diamond in the rough and we will not be able to keep them out.

 

[hamstergang]

My assistant PD would do surveys pre- and post-third year psych clerkships. His findings were that coming into the rotation, most students didn't think much of psychiatry. After the rotation, they liked psychiatry a lot more, but generally not enough to pick it as a specialty (the 3rd year rotation is a mix of inpatient and C/L). There's room for lots of interpretation and biases and all, but what I think we can get from this is that the first two years of medical school don't do enough to get students interested in psychiatry. It might not be sufficient, but why start at a disadvantage in the clinical years?

I think this can lead some students to mistake psychiatry as a"soft science." I wish Stahl's psychopharmacology could be incorporated a bit into the curriculum, or that cutting edge research in neuropsychiatry were discussed in more detail to demonstrate that this is not the case.

and psych being a soft science also baffles me. Again, I am biased because I like neuropsychiatry, but if you give any resident some articles from AJP or Biological Psychiatry, I'm sure they will agree that it is "hardcore" neuroscience. I mean, I"m presenting at journal club this week the recent publication in AJP on schizophrenics, drug naive, in western China who had MRI analysis of their cortices and other neuroanatomical areas. Hardcore neuroradiology that correlates with schzophrenia, and fascinating as well! Are Psychiatrists going to start ordering MRI Brain for every first break psychosis or monitoring of schizophrenia patients? Probably not, but this could be seen in the future, possibly 10-15 years. Just like how DBS for TRD might be the future, Ketamine, etc.

I agree with the others criticizing this view. That is, I don't think that the right response to viewing psychiatry as a soft-science is to bring up things outside/on the fringe of our evidence-base. A receptor/neurotransmitter approach seems reasonable and thoughtful, but doesn't seem to actually have support in the literature. Brain scans are interesting, but what have they actually gotten us clinically?

Instead, my preferred response is to show how scientific psychiatry actually is when practiced correctly. Science is a process. Sure, psych is somewhat lacking in the evidence-base, but the science process is certainly applicable. Understanding how to use the evidence that does exist is not soft.

 

[Blitz2006]

My assistant PD would do surveys pre- and post-third year psych clerkships. His findings were that coming into the rotation, most students didn't think much of psychiatry. After the rotation, they liked psychiatry a lot more, but generally not enough to pick it as a specialty (the 3rd year rotation is a mix of inpatient and C/L). There's room for lots of interpretation and biases and all, but what I think we can get from this is that the first two years of medical school don't do enough to get students interested in psychiatry. It might not be sufficient, but why start at a disadvantage in the clinical years?




I agree with the others criticizing this view. That is, I don't think that the right response to viewing psychiatry as a soft-science is to bring up things outside/on the fringe of our evidence-base. A receptor/neurotransmitter approach seems reasonable and thoughtful, but doesn't seem to actually have support in the literature. Brain scans are interesting, but what have they actually gotten us clinically?

Instead, my preferred response is to show how scientific psychiatry actually is when practiced correctly. Science is a process. Sure, psych is somewhat lacking in the evidence-base, but the science process is certainly applicable. Understanding how to use the evidence that does exist is not soft.

Point well taken, but I also think you missed my point. What I was trying to say is that to attract more hardcore science people, we need to enlighten them on the future of psychiatry. We have had SSRIs/Benzos/Clozaril around for 30 years, but its not doing a good job of attracting students. So we need to show people that the future is bright (which it is), and that there are new interventions on the horizon, such as possibly MRI imaging, Ketamine, etc.

Right now I have a medical student who is interested in Neurology, and after showing her this article she was amazed that there is a lot of neuroimaging potential in psych. She also had no idea that neuropsychiatry was a fellowship! So while I have the utmost respect for our neuro friends, I have no problem with poaching a future neurologist into a psychiatrist 🙂

 

[shan564]

I think it's the "real doctor" thing. Lots of people really want to go into psychiatry, but balk because they just can't commit due to the reluctance to hang up the stethoscope.

 

[splik]

I
Are Psychiatrists going to start ordering MRI Brain for every first break psychosis or monitoring of schizophrenia patients? Probably not, but this could be seen in the future, possibly 10-15 years. Just like how DBS for TRD might be the future, Ketamine, etc.

hopefully not, there is absolutely no indication to order an MRI brain for every first episode psychosis and most guidelines for FEP specifically state it is not recommended. Why would it be a possibility and why would this be a good thing? Also why would it be indicated for monitoring schizophrenia? Any changes on MRI (which are basically statistical using weird concepts like VBM anyway) are fixed - it is well known that progressive brain rot in patients with schizophrenia is a neuroleptic related

 

[clausewitz2]

hopefully not, there is absolutely no indication to order an MRI brain for every first episode psychosis and most guidelines for FEP specifically state it is not recommended. Why would it be a possibility and why would this be a good thing? Also why would it be indicated for monitoring schizophrenia? Any changes on MRI (which are basically statistical using weird concepts like VBM anyway) are fixed - it is well known that progressive brain rot in patients with schizophrenia is a neuroleptic related

I actually think that to the extent MRI is going to end up being useful for this field it is going to come more with functional studies in conjunction with somewhat more sophisticated classification algorithms than we have now, the sorts of classification algorithms that end up teasing out third-order patterns in connectivity data that no human radiologist, however well trained, is going to be able to spot reliably.

Also, there is a group that UNC that seems to think they're going to find structural changes in the brains of infants at risk for schizophrenia. Longitudinal work is underway, but there's at least some preliminary data from a couple of years ago: http://www.ncbi.nlm.nih.gov/pubmed/20516153

Generally though I am in broad agreement with you; we have been able to do head MRIs reliably since the 90's, and I don't see any reason to believe that a structural scan or two is ever going to yield useful information for management of psychiatric symptoms.

 

[technopoly]

Yikes, I agree with this. A lot of Stahl's stuff falls under what I'd consider pseudo-science (with an industry bent).... He tends to base a lot of his stuff off of studies done by the company's themselves. He delivered a talk during my residency and I wasn't very impressed when he was asked some pointed questions.

I am really glad to know that as I didn't before. Another view that was suggested to me by a psych faculty member is that psychiatry will be absorbed by neurology at some point in the future d/t advances in neuropsych. That seems unlikely to me, not least because of personality differences that draw each specialty to their respective patient populations.

 

[MacDonaldTriad]

I have learned not to trust in “great leaps forward”. Odds are 50 years from now we will be largely where we are now with some improvements or at least changes in the safety of our treatments, but efficacy will not change in one substantial leap. Our talk therapies will be evolved, but no matter what your belief system is, the main common denominator will be the formation of a therapeutic relationship and the expectation of improvement. At least this is the perspective of people who were in our field 50 years ago.

ECT, Thorazine and TCAs were a step forward for our field, but we are still largely were we were for personality disorders, addiction, and there are plenty of treatment resistant cases out there. Doubt neurology will take us over in anyone’s lifetime if you are already breathing.

 

[smalltownpsych]

The desire to make this a 'hard science" with machines and diagnostic tests is what leads us into the realm of pseudoscience. The science of human development of cognitive processes and emotions and the interaction between genetic and environmental factors and the interpersonal matrix of delivering treatment is what makes this the most challenging of specialties. One issue that the field has it that half of the experts are in a different profession. How many other specialties have the equivalent of psychologists working such similar turf?

 

[WingedOx]

I am really glad to know that as I didn't before. Another view that was suggested to me by a psych faculty member is that psychiatry will be absorbed by neurology at some point in the future d/t advances in neuropsych. That seems unlikely to me, not least because of personality differences that draw each specialty to their respective patient populations.

Yeah, when I "came out" as a potential psychiatrist to my parents, they both asked if psych would one day be taken over by neuro.

If you really want to answer that question, walk into a room full of neurologists and ask them "Hey, how many of you want to start dealing with more psych issues!?"

 

[Dharma]

It's been "the decade of the brain" for 3 decades...

 

[smalltownpsych]

I was just talking to a patient about all of the people who have well-functioning brains and then use them to make poor choices. This was a teen talking about peers who want to drop out because school is too hard. Just to make the point that many of our patients don't have identifiable neurological dysfunction and even the ones who probably do, we are pretty far from reliable diagnostic tests that point to a specific pharmacological treatment.

 

[smalltownpsych]

The desire to make this a 'hard science" with machines and diagnostic tests is what leads us into the realm of pseudoscience. The science of human development of cognitive processes and emotions and the interaction between genetic and environmental factors and the interpersonal matrix of delivering treatment is what makes this the most challenging of specialties. One issue that the field has it that half of the experts are in a different profession. How many other specialties have the equivalent of psychologists working such similar turf?

On the other hand, having the opportunity to work with psychologists could be considered a plus to being a psychiatrist. After all, we are known to be well-educated, solid researchers, have good clinical skills, critical thinking, and are all extremely physically attractive to boot. 😀

 

[metopic]

For me I think part of it was only doing inpatient. I'd likely have a better view if I did outpatient. But the other turn-off was the feeling that it wasn't based on data/science. I'm not saying that's true just that's how it felt.

We'd get an admission and the attending would come and be like "okay this is the plan we're adding on mirtazapine this'll work great." And then the next day the attendings would swap and the new one would be like "who $&#!ing added mirtazapine you aren't supposed to combine those drugs blah blah." Then the original guy would come back and I'd ask him about it and he'd be like "oh that's called california rocket fuel ppl who train in the west coast love it, the other guy is east coast they teach different." And that was a constant thing like we'd always be combining drugs in weird ways that textbooks/common sense would say is wrong or crazy just to "hey, see if this works." It felt like guess and check.

And the really sick people like the schizophrenics where you'd see them get better and back to functional it seemed so brainless. What do we do? who cares each attending is different but at the end of the day it's an antipsychotic drug that gets swapped to either invega sustena or risperdal consta before they DC.

We'd spend hours blabbing on and on and on with this whole team of people around the table and I wanted just be like WHO CARES HES SCHIZO GIVE HIM SEROQUEL AND LETS SEE HOW HE DOES. Like who cares how he's been behaving at home in excruciating detail he's clearly out of control get him some meds and lets talk in a few days. And then at the same time they'd basically ignore very obvious medical issues and be like "oh they can follow up outpatient" or get a medicine consult for the simplest crap. Is it really rocket science to give someone a little lisinopril and a sliding scale order set?

I felt like I wouldn't really learn anything from residency I didn't already know. My plans were never really "wrong" it was just which attending it was. Like this doc likes geodon more than seroquel.

And the evidence for a lot of SSRI stuff for depression seems dubious at best. In general psych research seems super influenced by drug companies.

In comparison my other rotations seemed very evidence based, the mechanisms made sense, and making the right diagnosis mattered. And the doc's never acted like huge pansies. Someone with an asymptomatic BP of 180/90 in surgery clinic? Here's a script for 30 days of chlorthalidone start it and follow up with IM clinic next week.

 

[hamstergang]

And the doc's never acted like huge pansies. Someone with an asymptomatic BP of 180/90 in surgery clinic? Here's a script for 30 days of chlorthalidone start it and follow up with IM clinic next week.

To comment on just this part, I actually think the psychiatrists have it right here. You don't want to get into the habit of prescribing medications you don't plan on following up. What happens if the patient doesn't make their IM clinic appointment, and now you're on the hook for renewing the medication until their next appointment? It's very easy to end up prescribing the med for longer than you would have planned initially, and you're responsible for monitoring it.

Plus, I'm spending all my time keeping up to date with psychiatry. I keep up with psychiatric literature, new drugs, new guidelines, etc. I can't do this for everything; that is, I can't also keep up with htn management and diabetic management and ... That's what IM docs are for. If this isn't something urgent (and asymptomatic htn that the pt likely had for a while already isn't urgent), then why rush to treat it? Let someone who better understands the nuances/guidelines for picking a starting treatment and monitoring target and adverse effects initiate treatment (or hold off on starting a med and suggest exercise first maybe). As a psychiatrist, I would be a little unhappy if a surgeon started a patient on a medication and then I get the patient and think meds aren't warranted. Now do I take the meds off and see how things go, or just go ahead and continue them since they're already on board?

 

[downwithDTB]

For me I think part of it was only doing inpatient. I'd likely have a better view if I did outpatient. But the other turn-off was the feeling that it wasn't based on data/science. I'm not saying that's true just that's how it felt....
And the evidence for a lot of SSRI stuff for depression seems dubious at best. In general psych research seems super influenced by drug companies.

In comparison my other rotations seemed very evidence based, the mechanisms made sense, and making the right diagnosis mattered. And the doc's never acted like huge pansies. Someone with an asymptomatic BP of 180/90 in surgery clinic? Here's a script for 30 days of chlorthalidone start it and follow up with IM clinic next week.

Yes! This nails it right on the head! For some reason, medical students seem to *love* ignoring all the complete arbitrariness of every other specialty. Which steroid inhaler to prescribe for asthma? Take your pick! Possibly slightly different side effect profiles. Different binding affinities... Want to see some serious attending dependent management? Head on over to the NICU. Let's talk pathophys: how does someone get MS? What is the specific cellular cascade that triggers it (or any disease in rheum for that matter). I have a hemodynamically stable patient with a fever, moderate abd pain and an ultrasound appy. Will their long term outcome (15 years) be better if I give abx and follow with q4h abd exams or take it out STAT? Management of perf'ed appys has gone 180, and there's a little evidence in favor of sitting on stable ones. And htn... how many bizarre med combos come through the ED in a given day? Non-compliant patients... it's can't get worse than IM or more depressing than OB. How many onc meds are directly targeted to the mutations known to exist in a given cancer? A few. And as far as drug companies influencing psych? Certainly not alone... every specialty has a bazillion versions of many drug classes with the latest being at best marginally better and heavily marketed... Tamiflu? You've got a high chance of n/v vs. a 0.5 day symptom benefit, yet it's pushed like no other, and perhaps the biggest pharm push that's likely lead to many ruined lives and deaths: the fifth vital sign campaign.

I think that the difference between psych and other disciplines is two fold: 1) brain function at the circuit level is still only understood at a very primitive level 2) psychiatrists tend to be more comfortable with the less well understood.

Of all physicians/surgeons, I like psychiatrists, as a group, the most. I sort of hope that it doesn't attract more/different folks or steal people away from derm and neurosurgery because I like the people that it's attracting now and want them (for the most part) to be my future colleagues.

 

[Ceke2002]

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'.

 

[HarryMTieboutMD]

My totally anecdotal, non evidence based thoughts (which have evolved over time through med school and now in my PGY2 year of residency):

For medical students who entertain the idea of psychiatry, often times the question, in some variation, is "am I REALLY going to medical school just to become a psychiatrist?" Implicit in this question is many of the sentiments listed above:
-"psychiatry isn't real medicine"
-"neurologists are the real brain doctors,"
-"this is pseudoscience"
-"psychiatrists don't make enough"
-"only bottom tier students/people who can't match into anything else go into psychiatry,"
-"Really? psychiatry?"
"No one will take me seriously as a doctor"
"People will confuse me with a psychologist"
"I'm not going to learn real doctor skills"
"Psychiatry is at the bottom of the totem pole"
Annnd... since medical school is like glorified high school... "the popular guys go into ortho/other surgery/EM/IM with intention of cards/GI/Pulm, and the popular girls do obgyn or derm. Only the weird people do psych..."

This is what I have seen from medical students, and this sentiment isn't changing any time soon. I think psych is becoming more "competitive" largely because everything is becoming more competitive with more US grads with a disproportionate increase in residency spots and USMLE score inflation.

And more MDPhDs are going into psych (THIS IS A GOOD THING) because the basic science research is getting better and better.

 

[Doctor Bagel]

To comment on just this part, I actually think the psychiatrists have it right here. You don't want to get into the habit of prescribing medications you don't plan on following up. What happens if the patient doesn't make their IM clinic appointment, and now you're on the hook for renewing the medication until their next appointment? It's very easy to end up prescribing the med for longer than you would have planned initially, and you're responsible for monitoring it.

Plus, I'm spending all my time keeping up to date with psychiatry. I keep up with psychiatric literature, new drugs, new guidelines, etc. I can't do this for everything; that is, I can't also keep up with htn management and diabetic management and ... That's what IM docs are for. If this isn't something urgent (and asymptomatic htn that the pt likely had for a while already isn't urgent), then why rush to treat it? Let someone who better understands the nuances/guidelines for picking a starting treatment and monitoring target and adverse effects initiate treatment (or hold off on starting a med and suggest exercise first maybe). As a psychiatrist, I would be a little unhappy if a surgeon started a patient on a medication and then I get the patient and think meds aren't warranted. Now do I take the meds off and see how things go, or just go ahead and continue them since they're already on board?

Yep, this. For example, when I did my IM rotation, we used metoprolol as a prn for hypertension, and we never used hydralazine. Now it seems like they're all using hydralazine as the prn of choice. Evidence based? Don't know. Either way, I'm a few years out of date with the best antihypertensives to use. I'm not entirely unwilling to start things, but I'm also more conservative about treating things like HTN and DM than I was as an PGY1 and PGY2 because those medicine months are farther behind me, meaning things I learned then are more likely to be out of date.

Also, can we not use the word schizo? With the poster above, if you're using that word, you're probably not headed into psych anyway. About people changing around medication regimens all the time, I think that's the pseudoscience Stahl type of stuff. That's also the grey area ambiguity stuff in psych -- there's often multiple right answers, so it's too bad your attendings were so quick to dismiss yours.

 

[HarryMTieboutMD]

For me I think part of it was only doing inpatient. I'd likely have a better view if I did outpatient. But the other turn-off was the feeling that it wasn't based on data/science. I'm not saying that's true just that's how it felt.

We'd get an admission and the attending would come and be like "okay this is the plan we're adding on mirtazapine this'll work great." And then the next day the attendings would swap and the new one would be like "who $&#!ing added mirtazapine you aren't supposed to combine those drugs blah blah." Then the original guy would come back and I'd ask him about it and he'd be like "oh that's called california rocket fuel ppl who train in the west coast love it, the other guy is east coast they teach different." And that was a constant thing like we'd always be combining drugs in weird ways that textbooks/common sense would say is wrong or crazy just to "hey, see if this works." It felt like guess and check.

And the really sick people like the schizophrenics where you'd see them get better and back to functional it seemed so brainless. What do we do? who cares each attending is different but at the end of the day it's an antipsychotic drug that gets swapped to either invega sustena or risperdal consta before they DC.

We'd spend hours blabbing on and on and on with this whole team of people around the table and I wanted just be like WHO CARES HES SCHIZO GIVE HIM SEROQUEL AND LETS SEE HOW HE DOES. Like who cares how he's been behaving at home in excruciating detail he's clearly out of control get him some meds and lets talk in a few days. And then at the same time they'd basically ignore very obvious medical issues and be like "oh they can follow up outpatient" or get a medicine consult for the simplest crap. Is it really rocket science to give someone a little lisinopril and a sliding scale order set?

I felt like I wouldn't really learn anything from residency I didn't already know. My plans were never really "wrong" it was just which attending it was. Like this doc likes geodon more than seroquel.

And the evidence for a lot of SSRI stuff for depression seems dubious at best. In general psych research seems super influenced by drug companies.

In comparison my other rotations seemed very evidence based, the mechanisms made sense, and making the right diagnosis mattered. And the doc's never acted like huge pansies. Someone with an asymptomatic BP of 180/90 in surgery clinic? Here's a script for 30 days of chlorthalidone start it and follow up with IM clinic next week.

This post is myopic, flawed, and ignorant in ever so many ways, and it reads strongly of the medical student-i know it all-therefore this rotation is beneath me mentality frequently seen on the wards. However, your attitude of "I felt like I wouldn't really learn anything from residency I didn't already know" is not only embarrassingly shortsighted, it's incredibly dangerous, irrespective of whatever specialty in which you decide to train. If any time as a physician, at any level of training, you decide that you know all you need to know and that any further reading, etc wouldn't affect your clinical practice, you have FAILED as a physician. And this applies 100% to psychiatry. This is one of the many aspects of being a physician that separates us from midlevels- we know what we don't know- and those of us who are committed to our careers strive to keep learning more.

 

[Psychotic]

This post is myopic, flawed, and ignorant in ever so many ways, and it reads strongly of the medical student-i know it all-therefore this rotation is beneath me mentality frequently seen on the wards. However, your attitude of "I felt like I wouldn't really learn anything from residency I didn't already know" is not only embarrassingly shortsighted, it's incredibly dangerous, irrespective of whatever specialty in which you decide to train. If any time as a physician, at any level of training, you decide that you know all you need to know and that any further reading, etc wouldn't affect your clinical practice, you have FAILED as a physician. And this applies 100% to psychiatry. This is one of the many aspects of being a physician that separates us from midlevels- we know what we don't know- and those of us who are committed to our careers strive to keep learning more.

Thank you for posting this. I was too tired (or digusted) to bother to reply to that post.

Hey, if psychiatry is not for you - great - don't let the door smack you on the butt on the way out of this forum...

 

[Ceke2002]

For me I think part of it was only doing inpatient. I'd likely have a better view if I did outpatient. But the other turn-off was the feeling that it wasn't based on data/science. I'm not saying that's true just that's how it felt.

We'd get an admission and the attending would come and be like "okay this is the plan we're adding on mirtazapine this'll work great." And then the next day the attendings would swap and the new one would be like "who $&#!ing added mirtazapine you aren't supposed to combine those drugs blah blah." Then the original guy would come back and I'd ask him about it and he'd be like "oh that's called california rocket fuel ppl who train in the west coast love it, the other guy is east coast they teach different." And that was a constant thing like we'd always be combining drugs in weird ways that textbooks/common sense would say is wrong or crazy just to "hey, see if this works." It felt like guess and check.

And the really sick people like the schizophrenics where you'd see them get better and back to functional it seemed so brainless. What do we do? who cares each attending is different but at the end of the day it's an antipsychotic drug that gets swapped to either invega sustena or risperdal consta before they DC.

We'd spend hours blabbing on and on and on with this whole team of people around the table and I wanted just be like WHO CARES HES SCHIZO GIVE HIM SEROQUEL AND LETS SEE HOW HE DOES. Like who cares how he's been behaving at home in excruciating detail he's clearly out of control get him some meds and lets talk in a few days. And then at the same time they'd basically ignore very obvious medical issues and be like "oh they can follow up outpatient" or get a medicine consult for the simplest crap. Is it really rocket science to give someone a little lisinopril and a sliding scale order set?

I felt like I wouldn't really learn anything from residency I didn't already know. My plans were never really "wrong" it was just which attending it was. Like this doc likes geodon more than seroquel.

And the evidence for a lot of SSRI stuff for depression seems dubious at best. In general psych research seems super influenced by drug companies.

In comparison my other rotations seemed very evidence based, the mechanisms made sense, and making the right diagnosis mattered. And the doc's never acted like huge pansies. Someone with an asymptomatic BP of 180/90 in surgery clinic? Here's a script for 30 days of chlorthalidone start it and follow up with IM clinic next week.

Psychiatry's not for you? Great, please never become one. If you couldn't even pull your head out your ar5e long enough to try and understand why a patient presenting with a psychotic disorder might need to have things like their behaviour at home versus hospital discussed in 'excruciating detail', instead of just tossing antipsychotics at them, then you have absolutely no business working in mental health care.

P.S kindly eff off with your 'pansies' crap as well.

 

[Doctor Bagel]

Psychiatry's not for you? Great, please never become one. If you couldn't even pull your head out your ar5e long enough to try and understand why a patient presenting with a psychotic disorder might need to have things like their behaviour at home versus hospital discussed in 'excruciating detail', instead of just tossing antipsychotics at them, then you have absolutely no business working in mental health care.

P.S kindly eff off with your 'pansies' crap as well.

Reminds me of a painfully detailed discussion on my surgery rotation of different bag types for a laparoscopic splenectomy. I'd much rather talk in excruciating detail about psychosocial factors.

 

[Leo Aquarius]

Okay, maybe not "everyone", but more often than any other specialty, I always hear physicians/prospective physicians say "I was thinking about going into psych, but xyz happened". What do you think this is caused by? The internal insecurity of not being looked at as a "real doctor" by friends, family, medical colleagues, etc? The pay (which is not a very legitimate reason if said person has done his/her research regarding pay in psychiatry)? What do you guys think can be done to increase interest in psychiatry among medical students and make it go from "I almost chose psychiatry" to "I did choose psychiatry"?

When people say "not real doctors," what they really mean is "not using medical knowledge much," which is possible in psych.

You see, psychiatry has the option - you can go through entire days without using medical knowledge if you do therapy, or you can be knee deep in medicine as an attending on the floors of a hospital doing consult work. Since the majority of psychiatry is private outpatient, there's not much emphasis or utilization of medical knowledge apart from pharmacology/kinetics/dynamics and how these impact other disorders/diseases/systems. That's about it.

I picked a fellowship that puts me back into medical knowledge on a daily basis, and am deeply happy with that choice. I'm reading lots of medical books now that I wouldn't otherwise, realizing how much I missed medical knowledge. Psychiatry is what you make of it.

 

[MacDonaldTriad]

Whenever I am asked if I ever regretted not becoming a real doctor, I just smile knowingly. The worst reaction we can have is to become defensive about it and launch into some kind of unasked for educational lecture about our specialty. I liked the above analogy of the cool kids in high school. It is time we grow out of worrying about identified clicks. Outside of medicine, these are much less understood and our patients never question our identity as physicians. How frightening would that be; “Well I have a chronic psychotic illness that I think I will let him manage, he doesn’t seem like a real doctor, but I think I’ll do what he says anyway.”

 

[Psychotic]

When people say "not real doctors," what they really mean is "not using medical knowledge much," which is possible in psych.

You see, psychiatry has the option - you can go through entire days without using medical knowledge if you do therapy, or you can be knee deep in medicine as an attending on the floors of a hospital doing consult work. Since the majority of psychiatry is private outpatient, there's not much emphasis or utilization of medical knowledge apart from pharmacology/kinetics/dynamics and how these impact other disorders/diseases/systems. That's about it.

I picked a fellowship that puts me back into medical knowledge on a daily basis, and am deeply happy with that choice. I'm reading lots of medical books now that I wouldn't otherwise, realizing how much I missed medical knowledge. Psychiatry is what you make of it.

Are you in that fellowship now? Did you go straight into it from residency, or did you work for some time after residency?

Oh, and what fellowship is it? C/L?

I am only a second year, but I think about these things...

 

[smalltownpsych]

http://drpete.co/are-you-a-real-doctor
Here's a good reference for all of us not real doctor types. 😉

 

[Armadillos]

This post is myopic, flawed, and ignorant in ever so many ways, and it reads strongly of the medical student-i know it all-therefore this rotation is beneath me mentality frequently seen on the wards. However, your attitude of "I felt like I wouldn't really learn anything from residency I didn't already know" is not only embarrassingly shortsighted, it's incredibly dangerous, irrespective of whatever specialty in which you decide to train. If any time as a physician, at any level of training, you decide that you know all you need to know and that any further reading, etc wouldn't affect your clinical practice, you have FAILED as a physician. And this applies 100% to psychiatry. This is one of the many aspects of being a physician that separates us from midlevels- we know what we don't know- and those of us who are committed to our careers strive to keep learning more.

Although there are certainly psychiatrists out there who practice in ways that make it seem like there is nothing you need to learn in residency, so I can see how medstudents get this impression, especially from inpatient psychiatry rotations. Honestly even as a resident I sort of feel that way a little bit at times. If your coming onto a medicine service your getting meticulous hand off, Im reading furiously about conditions I had never even heard of, scrutinizing labs to be sure Im not going to kill someone in the morning,etc.

But on the other hand I can walk onto a psych unit, round on 35 inpatients on a weekend for 2 days with nothing but a list of names with meds written next to them. You just decline all requests for narcs/benzos and patients chill till the social workers eventually find them a place to live. Psych seems unique in that its a field where the higher end thinking/expertise is required outpatient instead of inpatient. Compared to other specialties where clinic is the thing you kind of cruise through in autopilot mode (hence why PA/NP are so common in sub-specialty clinics these days) and inpatient is where the real thinking happens. So as a medstudent you get a strange picture of psych at most programs.

 

[Doctor Bagel]

Although there are certainly psychiatrists out there who practice in ways that make it seem like there is nothing you need to learn in residency, so I can see how medstudents get this impression, especially from inpatient psychiatry rotations. Honestly even as a resident I sort of feel that way a little bit at times. If your coming onto a medicine service your getting meticulous hand off, Im reading furiously about conditions I had never even heard of, scrutinizing labs to be sure Im not going to kill someone in the morning,etc.

But on the other hand I can walk onto a psych unit, round on 35 inpatients on a weekend for 2 days with nothing but a list of names with meds written next to them. You just decline all requests for narcs/benzos and patients chill till the social workers eventually find them a place to live. Psych seems unique in that its a field where the higher end thinking/expertise is required outpatient instead of inpatient. Compared to other specialties where clinic is the thing you kind of cruise through in autopilot mode (hence why PA/NP are so common in sub-specialty clinics these days) and inpatient is where the real thinking happens. So as a medstudent you get a strange picture of psych at most programs.

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.

 

[DD214_DOC]

We need to get students out of inpatient psychiatry and show them something more representative of what we do.

Med students are very susceptible to charismatic mentors. We just need to prioritize teaching more and have departments value teaching.

I repeated this every year after my outpatient year, and really encouraged the rotating med students to seek out exposure to outpatient psych on their own. Many get turned off by their experiences on inpatient psych, c/l, or acute crisis stuff, and understandably so. The real fun is outpatient psych.

 

[splik]

But on the other hand I can walk onto a psych unit, round on 35 inpatients on a weekend for 2 days with nothing but a list of names with meds written next to them. You just decline all requests for narcs/benzos and patients chill till the social workers eventually find them a place to live. Psych seems unique in that its a field where the higher end thinking/expertise is required outpatient instead of inpatient. Compared to other specialties where clinic is the thing you kind of cruise through in autopilot mode (hence why PA/NP are so common in sub-specialty clinics these days) and inpatient is where the real thinking happens. So as a medstudent you get a strange picture of psych at most programs.

I just don't think this is true. you can be just as mindless (even more actually as the patients are likely more stable) in outpatient as you can on an inpatient unit. It's really an indictment of how we care for the mentally ill in this country, that we think it's acceptable to round on 35 inpatients with nothing but a list of names with meds written next to them. call it what you will but it's not psychiatry.

 

[Doctor Bagel]

I just don't think this is true. you can be just as mindless (even more actually as the patients are likely more stable) in outpatient as you can on an inpatient unit. It's really an indictment of how we care for the mentally ill in this country, that we think it's acceptable to round on 35 inpatients with nothing but a list of names with meds written next to them. call it what you will but it's not psychiatry.

And what type of medical school exposes students to this type of work? Sure, patient volumes on the weekends are higher everywhere, but I can't imagine an academic hospital having 35 patients for one provider on any day.

 

[Leo Aquarius]

Are you in that fellowship now? Did you go straight into it from residency, or did you work for some time after residency?

Oh, and what fellowship is it? C/L?

I am only a second year, but I think about these things...

I tried sending you a private message but that option doesn't appear on your profile. Odd. Feel free to PM me 🙂

 

[smalltownpsych]

Although there are certainly psychiatrists out there who practice in ways that make it seem like there is nothing you need to learn in residency, so I can see how medstudents get this impression, especially from inpatient psychiatry rotations. Honestly even as a resident I sort of feel that way a little bit at times. If your coming onto a medicine service your getting meticulous hand off, Im reading furiously about conditions I had never even heard of, scrutinizing labs to be sure Im not going to kill someone in the morning,etc.

But on the other hand I can walk onto a psych unit, round on 35 inpatients on a weekend for 2 days with nothing but a list of names with meds written next to them. You just decline all requests for narcs/benzos and patients chill till the social workers eventually find them a place to live. Psych seems unique in that its a field where the higher end thinking/expertise is required outpatient instead of inpatient. Compared to other specialties where clinic is the thing you kind of cruise through in autopilot mode (hence why PA/NP are so common in sub-specialty clinics these days) and inpatient is where the real thinking happens. So as a medstudent you get a strange picture of psych at most programs.

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.

 

[Psychotic]

I tried sending you a private message but that option doesn't appear on your profile. Odd. Feel free to PM me 🙂

My settings were very restrictive. Funny thing is I don't ever remember setting them...

Anyway, I can now receive PMs, but you got one from me, too. Thanks.

 

[WingedOx]

I repeated this every year after my outpatient year, and really encouraged the rotating med students to seek out exposure to outpatient psych on their own. Many get turned off by their experiences on inpatient psych, c/l, or acute crisis stuff, and understandably so. The real fun is outpatient psych.

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!.

 

[aspiringdoc09]

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!.

Lol. That's what I didn't like so much about outpatient when I shadowed for 2 weeks. It seemed a bit boring compared to impatient but it was good to see that the patients were capable of functioning/improving over the long-term. Of course, you still have to make adjustments but that is medicine. The boring part was that I worked at a site where patients didn't always show up for appointments so we had blocks of time dwindling our thumbs. I didn't have to study anything because I was a rising M2, so....

The days I could stick around past 5 for extended visits or listen to the attending shop talk and teach his residents was awesome. I even enjoyed being able to interview and present to the attending and come up with an A/P.

 

[WingedOx]

Lol. That's what I didn't like so much about outpatient when I shadowed for 2 weeks. It seemed a bit boring compared to impatient but it was good to see that the patients were capable of functioning/improving over the long-term. Of course, you still have to make adjustments but that is medicine. The boring part was that I worked at a site where patients didn't always show up for appointments so we had blocks of time dwindling our thumbs. I didn't have to study anything because I was a rising M2, so....

The days I could stick around past 5 for extended visits or listen to the attending shop talk and teach his residents was awesome. I even enjoyed being able to interview and present to the attending and come up with an A/P.

Yeah, as psychiatry we have the best discussions. Can't argue that.

 

[DD214_DOC]

Lol. That's what I didn't like so much about outpatient when I shadowed for 2 weeks. It seemed a bit boring compared to impatient but it was good to see that the patients were capable of functioning/improving over the long-term. Of course, you still have to make adjustments but that is medicine. The boring part was that I worked at a site where patients didn't always show up for appointments so we had blocks of time dwindling our thumbs. I didn't have to study anything because I was a rising M2, so....

The days I could stick around past 5 for extended visits or listen to the attending shop talk and teach his residents was awesome. I even enjoyed being able to interview and present to the attending and come up with an A/P.

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?