Psychiatry resident - ask me anything

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Styrene

Psychiatry Resident (PGY-4)
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Don't think this has been done for several years now, not sure, and there's been an uptick in medical student interest in the field. Anybody out there?

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Why all the sudden interest in putting old people on depakote? Is there new literature? How do you treat delusional parasitosis in an ED setting when you can't admit to psych and can't get someone rapidly into derm? Are you prescribing naltrexone for masturbation addiction? What exactly makes IM thorazine better for people who have inadequate releif of agitation with droperidol? It seems like there's been an uptick in what I deem to be subclinical thc induced psychosis with the legally available high test concentrates, has this been described? Have you ever seen an old lady who's been on high dose benzos their whole life, and they just have this chronic high level of anxiety and fear and incapablity to deal with change even if they have a therapeutic amount of benzos on board? What do you call that?
 
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Why all the sudden interest in putting old people on depakote? Is there new literature? How do you treat delusional parasitosis in an ED setting when you can't admit to psych and can't get someone rapidly into derm? Are you prescribing naltrexone for masturbation addiction? What exactly makes IM thorazine better for people who have inadequate releif of agitation with droperidol? It seems like there's been an uptick in what I deem to be subclinical thc induced psychosis with the legally available high test concentrates, has this been described? Have you ever seen an old lady who's been on high dose benzos their whole life, and they just have this chronic high level of anxiety and fear and incapablity to deal with change even if they have a therapeutic amount of benzos on board? What do you call that?

1) For whatever reason, Depakote is viewed as a "safer" or "gentler" alternative to atypical antipsychotics for older patients given the black box warning with atypical antipsychotics and other adverse effects. But there are plenty of adverse effects of Depakote that are, as usual, worse in older patients. I've seen many patients with neurocognitive disorders who are on Depakote. Anecdotally, it helps (ie, for impulsivity/agitation), but there is rather weak literature at best to support this particular use.

2) Assuming we are acting in a consultation role, delusional parasitosis per se is not a diagnosis treated with inpatient psychiatric admission. But, of course, it can be seen in the setting of numerous other disorders, commonly substance and alcohol use disorders and potentially more broad psychotic disorders, which can require admission. But for delusional parasitosis only, there isn't a useful psychiatric treatment that fits with the logistics of the medical ER for the disorder itself. Such patients can be referred for outpatient psychiatric treatment. Antipsychotic medications might help some patients, but this intervention requires longitudinal assessment and monitoring.

3) I've never treated a patient with compulsive masturbation or reviewed literature about naltrexone for such, so I don't know if naltrexone is being used in that regard. It might help some patients depending on the etiology of the behavior.

4) Thorazine is very sedating due to the pharmacodynamic profile, but droperidol works well, too. In the exact situation you describe, it's probably a combination of more time passing (acute agitation often resolves on it's own in a couple hours, depending on what's going on) and cumulative effect of the drugs (droperidol first and then Thorazine if droperidol was ineffective). I never use droperidol and rarely use Thorazine.

5) It probably has been described, but I can't tell you the specifics of it. It's definitely the case from what I've seen.

6) It can be a benzodiazepine-induced anxiety disorder with an ongoing cycle of between-dose benzodiazepine withdrawal. Some of these patients can even be in a state of perpetual withdrawal at the receptor level. I believe benzodiazepines can cause permanent damage. I've seen innumerable patients with this issue. On the other hand, it can be poorly treated "primary" anxiety disorder. Benzodiazepines do not treat anxiety disorders effectively in the long term for the vast majority of patients. A few I have helped to finally discontinue benzodiazepines, and others remain on them forever. There are also a million possible contributory factors here. That's the thing about psychiatry: We deal with syndromes comprised of behavioral and psychosocial manifestations of unknown cause, so it's impossible to say what's really going biologically like in a disease model. Take 1000 patients with bipolar disorder. Is there a shared single pathophysiologic brain process, maybe a few possible ones, or is there a wholly unique pathophysiologic brain process for each individual?
 
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Don't think this has been done for several years now, not sure, and there's been an uptick in medical student interest in the field. Anybody out there?
What other specialties were you considering in med school? If you had to choose something else, what would it be?

How many of your peers would you consider introverted versus extroverted?
 
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What other specialties were you considering in med school? If you had to choose something else, what would it be?

How many of your peers would you consider introverted versus extroverted?

1) An ortho guy saved my dad's leg years ago, and I ended up shadowing him for a day or two in the clinic as an early premed. He was awesome, so, naturally, I was interested in orthopedic surgery. A couple years later while still in undergrad, I did EM research, much of it about head CTs, and radiology completely captured my imagination. So this is where my thinking was leading up to medical school.

Quickly during/after anatomy, our first class in my medical school, I realized I could not stand anything with cutting, using tools, etc, so all forms of surgery were out. But I loved the radiologic anatomy sections of our general anatomy course. I went on to do radiology research during my first couple years in medical school--a couple studies on MRI and radiomics, which couldn't be completed after IRB approval because of staffing changes and funding issues, and an abstract and poster at a national conference. Radiology was what I for sure wanted to do by that point. There were other projects in the works and future plans for additional mentorship.

Come clerkships, I was still certain I would pursue diagnostic radiology. However, I have an eye problem (keratoconus) that worsened to the point of being forced to keep an open mind about specialty choice. I could then and still do see just fine, but what if I needed a corneal transplant suddenly? Luckily for me, that sliver of doubt morphed into an identify crisis after a couple weeks during my psychiatry clerkship, about halfway through third year. I just absolutely loved getting to know patients with mental illness, and psychopharmacology really captured my imagination, and I had a lot of natural skill for it all. After shedding some tears and reflecting, running things by my friends and family, I went wholeheartedly with psychiatry and never looked back. One of the best choices I ever made. Now I'm here.

If things hadn't lined up this way, I probably would have applied for radiology or internal medicine. If the latter, I could see myself in general hospital medicine, rheumatology, endocrinology, or critical care. As for radiology, I'd get by just fine, but I'd probably have migraines from staring at the computer all day due to my chronic dry eye disease and keratoconus. Specialties I would never consider: pediatrics, general surgery, surgical subspecialties, OB/GYN. I would probably love pathology (I wanted to be a forensic pathologist in high school), but I didn't go that route for several reasons, mainly because we hardly have exposure to it when we are in the most active phase of choosing a specialty.


2) I discussed this with my co-chief today after seeing the question. In our program, it's about 50/50 introverted and extraverted. I am strongly introverted, maybe even 20% schizoid-like, perhaps a bit socially anxious, but in the structured clinical environment, I have no issues. I find it a strength, for me, given the near 100% purely cerebral work of psychiatry (way less "work work" than other specialties). Being contemplative and slow to act can be a real asset in psychiatry. Extraverted psychiatrists have their own strengths. They flourish in the emergency setting, for example, in handling acute situations, in communication with interdisciplinary team, making things happen, but they can obviously do well in all ways. We balance each other out in the collaborative academic setting. Interesting question!
 
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Do you every take primary on surgery patients with really bad delirium? Like..really bad
 
any insight into how your program/other psych programs rank applicants?
 
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How has the more recent emphasis on mental health changed residency (competition, interprofessional or scope challenges with PsyD/similar, reimbursements and work load)? Especially post pandemic.
 
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How has the more recent emphasis on mental health changed residency (competition, interprofessional or scope challenges with PsyD/similar, reimbursements and work load)? Especially post pandemic.

Access to psychiatric care is worse.

Under the guise of access, tons of online telepsych companies popped up during the pandemic, staffed mostly by NPs, to push adult ADHD and stimulants, causing a medication shortage. Now that they're out of business, we are flooded by their refugees seeking a psychiatrist to continue their inappropriate medications, which causes a longer wait time for those who have a legitimate need for psychiatric treatment. These refugees can turn hostile when requests to continue inappropriate controlled substances are turned down, which makes for an unpleasant work environment.
 
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Currently a 3rd year student that will be applying psychiatry this upcoming cycle.

Is there a specific, reasonable, skill-set(s) that you wish you could’ve started honing in on earlier as a medical student on clinical rotations that would’ve set you up for success as a psychiatry resident?
 
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any insight into how your program/other psych programs rank applicants?
Speaking from my general experience, psychiatry programs first do look at all of the basics, including performance/ranking in medical school, performance on Step 2, extracurricular activities/research, writing skill as evidenced by personal statement, and letters of recommendation a certain number of which really ought to be from psychiatrists (specifics probably vary by program). Interviews are the next step. Interviews are very important. Psychiatry programs place a great emphasis on interest in and dedication to psychiatry. This can be demonstrated in a number of ways during the interviews, like memorable patient cases, how an applicant speaks about psychiatry generally, etc. We also may be quite attuned to quirks in communication, personality factors, and verbal communication abilities, all of which may affect a person's potential as a psychiatrist. Each interview would rate who they interview, in any number of ways, and report back to the PD who ultimately will create a final rank list. Often, applicants are discussed in an open forum committee meeting, as well, after interviews. The process, of course, will vary by program. But that is a general outline. If there are elements of an application that hint at a lack of genuine interest in the field, it may become a negative. If anything like this is glaring, like only having dermatology research all through medical school, applicants ought to bring it up.

One of the best/worst things a person can do is an away rotation. If an applicant really performed well, it will be talked about among faculty/chiefs, and it is the greatest boost to an application. The converse is true, as well.
 
How has the more recent emphasis on mental health changed residency (competition, interprofessional or scope challenges with PsyD/similar, reimbursements and work load)? Especially post pandemic.
1) The competitiveness of applying to psychiatry residency has definitely increased. I have friends from a few years ago with incredible applications and great personalities who matched way down on their rank lists. Twenty years ago, 260+ Step scores, numerous publications, etc, would probably match higher on rank order. Don't have numbers to back it up--just personal experience seeing friends and acquaintances match here or there over the years. And where I am, the number of psychiatry applicants from our medical school has skyrocketed from about 4-6 per class to as many as 17, which has been surprising but also delightful.

2) I have not run into scope of practice issues directly during residency (at least not face to face). However, the number of psychiatric NPs has seemingly ballooned. There hasn't been a notable effect in patient volumes on our end, but we do see many, many patients in the emergency room, inpatient unit, med/surg hospital, and outpatient clinic who present in the context of sometimes severe mismanagement as the result of seeing a nurse practitioner. Some NPs are fantastic, others are reprehensible knowingly or not. The PNP degree is low hanging fruit. Everyone wants to do it now.

3) During the pandemic, the workload dramatically increased on psychiatry consultation services because any time a patient tested positive for COVID in the psych ER, they went to medicine. Many of these patients were severely mentally ill, aggressive, and violent, requiring psychiatric admission, and we had to manage that on the medical floor for the 10-14 day quarantine period. This increase stress all around. It still goes on but to a much lesser extent. The outpatient workload remains high due to overall increase in demand. The waitlist at our clinic for med management is six months. For therapy, it can be even longer depending on the situation. Doesn't matter how many people are hired. It's just impossible to catch up with the demand for now.
 
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Currently a 3rd year student that will be applying psychiatry this upcoming cycle.

Is there a specific, reasonable, skill-set(s) that you wish you could’ve started honing in on earlier as a medical student on clinical rotations that would’ve set you up for success as a psychiatry resident?
The core skills learned during clinical rotations in medical school are also very important for psychiatry, so always focus on those.

THE important psychiatry-specific skill is the psychiatric interview. In a way it is like other specialties, but mostly not. Get as much experience doing that as possible. Ideally, the psychiatric interview can be conducted as a friendly, supportive conversation during which the patient is put at ease, the therapeutic alliance is created, and all of the pertinent information is collected. The key components are HPI, psychiatric review of symptoms, psych history, social history, substance history, family history, medical history, mental state exam, impression and plan. Knowing the psychiatry-specific things that go in each of these sections should be mastered but will be a work in progress for years. Innumerable resources exist. Briefly, HPI as the patient story about recent events, psych review of symptoms covering present and past symptoms of the major symptom domains (depression, mania, psychosis, anxiety, suicidality, aggressive/violence), psychiatric history as a narrative of the patient experience/engagement with psychiatric treatment (first hospitalization, number of hospitalizations, medications tried and effectiveness vs adverse effects, any suicide history, etc), and so forth. If you can get through all of those, even if only basically, and in a timely manner (20-30 minutes), while establishing a therapeutic alliance with the patient, you will be functioning at a level above many psychiatry interns at the start of residency. Invariably, medical students start off well but then freeze after five minutes. Let the patient speak for a bit and then gather the histories! Ask permission to inquire about sensitive topics. Be open-ended and inquisitive. Ask about suicidal/homicidal thoughts, don't be shy. Have a calm and reassuring demeanor. I can go on and on...

Best of luck to you during the application process!
 
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Do you every take primary on surgery patients with really bad delirium? Like..really bad
Delirium should not be given to psych as primary. There's an underlying medical issue causing the delirium. Treat that, and give haldol if needed for agitation
 
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Delirium should not be given to psych as primary. There's an underlying medical issue causing the delirium. Treat that, and give haldol if needed for agitation
I can now infer what was meant by the original question. Yes, delirium is medical 99.99% of the time. There are ultra-rare psychiatric, albeit heterogeneous, versions of delirium (malignant catatonia, delirious mania), but these often require medical care, as well. If delirium is causing agitation that poses an immediate safety risk or interferes with medical care, then treatment with Haldol the specifics of which vary by case. If it is hypoactive delirium, treating with Haldol can prolong delirium and worsen delirium. If too much sedative is given to a hyperactively delirious patient, they may convert to hypoactive delirium, which has a worse prognosis. Our idea now is that there is no psychopharmacologic treatment for delirium, per se, so other factors ought to be addressed, first being treating the underlying medical condition and/or searching for as yet to be discovered medical causes.
 
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How has the more recent emphasis on mental health changed residency (competition, interprofessional or scope challenges with PsyD/similar, reimbursements and work load)? Especially post pandemic.
Can't speak to how it's impacted residency since I graduated in 2019 before the pandemic. But man for sure the pandemic and the rise of social media has everyone and their dog/mother thinking they're autistic and have adhd because they watched a tik tok video that they identify with
 
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Can't speak to how it's impacted residency since I graduated in 2019 before the pandemic. But man for sure the pandemic and the rise of social media has everyone and their dog/mother thinking they're autistic and have adhd because they watched a tik tok video that they identify with
I didn't get to child psychiatry in my response. But yes, it's so out of control. At one point, our child unit was filled with preteens convinced they had Tourette syndrome and homicidal command verbal hallucinations.

Edit: Even worse if they saw an unknowledgeable NP. I saw one 14 year old who was already on max dose Zyprexa, Lexapro, and Klonopin through an NP.
 
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I didn't get to child psychiatry in my response. But yes, it's so out of control. At one point, our child unit was filled with preteens convinced they had Tourette syndrome and homicidal command verbal hallucinations.

Edit: Even worse if they saw an unknowledgeable NP. I saw one 14 year old who was already on max dose Zyprexa, Lexapro, and Klonopin through an NP.
It’s for sure out of control. The number of people who self diagnose “neurodivergent” and think they’re autistic is astounding. Huge increase since I completed residency in 2019. I was military for 4 years after and just finished my commitment this last summer and started full civ practice (which I love). But multiple patients a day think they have adhd because they “can’t focus” but were straight A students with zero impairment all the way through their 3rd master’s program but suddenly had “adult adhd”.
 
But since we’re in a med student forum I’ll say this is about my only real complaint with psychiatry. I love my job. I work 4 days a week 10 hour days and get every Friday off. No nights, no call, no weekends, great benefits, straight outpatient. I did really enjoy inpatient and there are some really good gigs out there but I love my schedule so far working outpatient. I’m only like 6 months in but looks like I’m on pace to clear 300K with potential for much more. The clinic I work for has multiple clinics in multiple states and other psychiatrist are pulling 400+ so it’s definitely doable in psychiatry to make very good money and have a very good lifestyle.
 
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Sorry I didn’t mean to derail the thread from asking a resident (since I’m not a resident lol), just wanted to provide some post residency perspective as well. Carry on and your responses are spot on to the questions above.
 
The core skills learned during clinical rotations in medical school are also very important for psychiatry, so always focus on those.

THE important psychiatry-specific skill is the psychiatric interview. In a way it is like other specialties, but mostly not. Get as much experience doing that as possible. Ideally, the psychiatric interview can be conducted as a friendly, supportive conversation during which the patient is put at ease, the therapeutic alliance is created, and all of the pertinent information is collected. The key components are HPI, psychiatric review of symptoms, psych history, social history, substance history, family history, medical history, mental state exam, impression and plan. Knowing the psychiatry-specific things that go in each of these sections should be mastered but will be a work in progress for years. Innumerable resources exist. Briefly, HPI as the patient story about recent events, psych review of symptoms covering present and past symptoms of the major symptom domains (depression, mania, psychosis, anxiety, suicidality, aggressive/violence), psychiatric history as a narrative of the patient experience/engagement with psychiatric treatment (first hospitalization, number of hospitalizations, medications tried and effectiveness vs adverse effects, any suicide history, etc), and so forth. If you can get through all of those, even if only basically, and in a timely manner (20-30 minutes), while establishing a therapeutic alliance with the patient, you will be functioning at a level above many psychiatry interns at the start of residency. Invariably, medical students start off well but then freeze after five minutes. Let the patient speak for a bit and then gather the histories! Ask permission to inquire about sensitive topics. Be open-ended and inquisitive. Ask about suicidal/homicidal thoughts, don't be shy. Have a calm and reassuring demeanor. I can go on and on...

Best of luck to you during the application process!
Agree with this 100%. I typically start with new patients by opening with a welcome and then giving them the floor to just tell me what’s going on. Sometimes it’s brief and then I start asking more clarifying questions, sometimes they talk for a while. Either way I feel like this gives them the chance to express their concerns while also letting them know I’m listening. So far it’s been a pretty successful approach to making patients feel more comfortable so I can ask later some more personal questions regarding things like past trauma and suicidal thoughts. Typically don’t push too much with traumatic experiences on the first visit but can go more into later. I do vast majority med management and not so much therapy though so this may be a different approach from others who plan to engage in more therapy in subsequent appointments.
 
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Sorry I didn’t mean to derail the thread from asking a resident (since I’m not a resident lol), just wanted to provide some post residency perspective as well. Carry on and your responses are spot on to the questions above.
The more perspectives, the better. Thanks for all your input. It's been a nice thread so far.
 
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2) I have not run into scope of practice issues directly during residency (at least not face to face). However, the number of psychiatric NPs has seemingly ballooned. There hasn't been a notable effect in patient volumes on our end, but we do see many, many patients in the emergency room, inpatient unit, med/surg hospital, and outpatient clinic who present in the context of sometimes severe mismanagement as the result of seeing a nurse practitioner. Some NPs are fantastic, others are reprehensible knowingly or not. The PNP degree is low hanging fruit. Everyone wants to do it now.

While I haven't experience NP competition, as mentioned above, it's a pain to deal with NPs' former outpatients who were inappropriately prescribed and/or inappropriately diagnosed.

From the inpatient side, there is pressure from The Man to manage their NPs, as NPs are proxies for admin. They cost less and do whatever the hospital tells them. As a rule, NPs behave like nurses, meaning they don't adhere to the medical model. In addition to knowledge deficits (i.e., when I was a MS-3, I could read a NP's psych plan and tell they didn't know wtf they were doing), NPs respond to gentle teaching and recommendations like insults to their character and get passive aggressive. Whereas med students and residents crave feedback because they want to BE good doctors, not someone who PLAYS doctor 9-5 and passes the buck to a doctor. It's usually pointless to correct NPs unless you personally employ them (which is how it was meant to be).

In general, hospital gigs that utilize psychiatrists only, or use NPs in limited roles such as overnight call, are preferable to hospitals that have lots of NPs.
 
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While I haven't experience NP competition, as mentioned above, it's a pain to deal with NPs' former outpatients who were inappropriately prescribed and/or inappropriately diagnosed.

From the inpatient side, there is pressure from The Man to manage their NPs, as NPs are proxies for admin. They cost less and do whatever the hospital tells them. As a rule, NPs behave like nurses, meaning they don't adhere to the medical model. In addition to knowledge deficits (i.e., when I was a MS-3, I could read a NP's psych plan and tell they didn't know wtf they were doing), NPs respond to gentle teaching and recommendations like insults to their character and get passive aggressive. Whereas med students and residents crave feedback because they want to BE good doctors, not someone who PLAYS doctor 9-5 and passes the buck to a doctor. It's usually pointless to correct NPs unless you personally employ them (which is how it was meant to be).

In general, hospital gigs that utilize psychiatrists only, or use NPs in limited roles such as overnight call, are preferable to hospitals that have lots of NPs.
I have worked with a couple of really good NP’s that recognized they didn’t go to med school and would frequently consult me and another psychiatrist on things. But unfortunately there are quite a few out there that fit this description very well. I’ve inherited some patients from NP’s and I’m wondering wth they were doing with patients.
 
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