Reservations before applying psych

[trillianMcMillan]

Hi all - I'm an M3 deciding between psych vs IM vs combined. I'm leaning strongly towards categorical psych, mostly held back by some internal conflicts about psych that came up during my rotations, which I'm hoping are things I'll get over with time. I'm mainly seeking insight into - 1) if you've experienced any of these reservations, how did you work through them, & do they interfere with your satisfaction with psychiatry now? 2) are any of these big 'red flags' that tell you "this person will probably regret choosing psych"?, vs "I can see a place for this person in psych?"

Sorry in advance for the length - my main question here is really: 1) do you see 'people-pleaser' types, or people who feel conflicted about involuntary treatment really struggle to succeed & feel happy as psychiatrists?

For some background, I went into med school thinking I'd likely end up in psych - I had some prior experience as a psych aide, enjoyed working with patients with psych conditions, loved reading & learning about psych. My rotations reaffirmed all of that for me - I love psychiatric interviewing & evaluation, the theoretical foundations, and discussing/formulating plans particularly inpatient. At the same time I also found that I loved my time on non-interventional medicine specialties that involved a lot of patient counseling and shared decision-making. Overall from my rotations I know I (1) want to be a specialist eventually, (2) want a lot of time talking to patients, and (3) specifically love quality informed-consent and diagnosis conversations - learning what my patient knows about their condition/options, what they value, and tailoring counseling/recommendations based on that. My pet peeve is treating someone when we have no idea what their goals of care are (though I know that'll come up in any field). Also for context, my psych rotation was heavily outpatient >>> inpatient time, and the outpatient was a lot of meeting patients once and saying 'yes/no stimulant Rx'. early next year I'll be doing a true 1mo inpatient adult psych elective, which I imagine will inform my thinking a lot.

I think the main reason I've felt some pull away from psych relates to the ways it's hard to experience (3) as a med student in psych, vs. easier to experience as a med student in IM. On my IM rotation I had lots of opportunities to practice patient education, counseling and shared-decision-making. On my psych rotations I found a lot of my patient interactions were more paternalistic (involuntary treatment inpatient, refusing benzos or stimulants outpatient), and the frequency of conflict and power-struggles with patients was draining sometimes. I'm sure one reason for this is just that my knowledge base / ability to explain things to patients is stronger in IM > psych at this stage of my training, which I suspect will get better in psych residency. The thing that concerns me more is that there's a personality aspect - I'm a bit of a people-pleaser/doormat by nature, not naturally very good at saying 'no' or refusing patients' wishes, and it wears on me. I love when I can reach a place of mutual understanding with patients about their condition, and when patients' poor insight is part of their condition, it's hard to feel like I can understand or respect their wishes. I realize these will be issues in IM too- I'm just wondering if they're liable to cause more friction in psych.

The other / more minor hesitations I have about psych are more practical. I've gotten the sense that '?adult ADHD' referrals are an increasingly big part of outpatient psych, and while I'm happy to do adult ADHD evaluation & treatment sometimes, I know I don't want it to be the majority of what I do every day. Is this an issue for any of you, and how avoidable is it? (I don't mean to diminish the importance of ADHD with this / sorry if it comes off as flippant).

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[splik]

Your psych rotation sounds less than ideal and not typical of what most students get, but is unfortunately more reflective of wider practice. The good news is that psychiatry has a wide variety of practice settings and specialties so one can find their niche. Psychiatrists can work in private practice, clinics, general hospitals, state hospitals, academics, community mental health, homeless outreach, prisons, jails, schools, colleges, ICE detention, courts, residential treatment programs etc. Subspecialties include child, forensics, addictions, geriatrics, consultation-liaison, pain, palliative medicine, sleep medicine. Some specialize in psychotherapy (including psychoanalysis, CBT, DBT, ACT, group psychotherapy, couples therapy, family therapy etc), or neuromodulation. Some specialize predominantly or exclusively with certain patient populations such as eating disorders, PTSD, somatoform disorders, LGBTQ, perinatal, psycho-oncology etc.

I would encourage you to try to get a taste of some different aspects of psych beyond just inpatient and outpatient (even if it's just a day here and there). At the med school I worked at, we had a list of attendings who would allow students to shadow for as little as an hour or as long as a day, and had some mini electives (e.g. a week) for students to get more exposure. Contact your director of medical student education in psychiatry to see if they can assist.

There is a difference between being a people pleaser (which is most physicians) and being a doormat. You are going to struggle to be effective in any field except running a pill mill if you really struggle with this. You will also get taken advantage of by your colleagues and superiors. That said, most students and even junior residents will struggle with setting limits and saying "no" to patients. It is a skill you develop over time. Worst case scenario, you get shot. Best case, you could really transform someone's life.

RE: ADHD, while this will always be a common presentation for outpatient psych, it is also one of the latest in a long line of fads in psychiatry. 40 years ago people thought they had multiple personalities, 20 yrs ago everyone thought they had bipolar, now it's ADHD. There will be some other diagnosis in vogue at some point. And it's exactly the same patients each time round. The only difference is the fads are increasingly influenced by late stage capitalism (though people were claiming this over 40 years ago too!)

 

[slowthai]

(3) specifically love quality informed-consent and diagnosis conversations - learning what my patient knows about their condition/options, what they value, and tailoring counseling/recommendations based on that. My pet peeve is treating someone when we have no idea what their goals of care are (though I know that'll come up in any field).

I spent a lot of time doing this during my addiction rotation, and I also do this when I'm admitting patients on inpatient that have enough insight to participate in these discussions, particularly the detox pts, the MDD pts, and some of the bipolar/psychotic pts.

 

[Merovinge]

Your psych rotation sounds less than ideal and not typical of what most students get, but is unfortunately more reflective of wider practice. The good news is that psychiatry has a wide variety of practice settings and specialties so one can find their niche. Psychiatrists can work in private practice, clinics, general hospitals, state hospitals, academics, community mental health, homeless outreach, prisons, jails, schools, colleges, ICE detention, courts, residential treatment programs etc. Subspecialties include child, forensics, addictions, geriatrics, consultation-liaison, pain, palliative medicine, sleep medicine. Some specialize in psychotherapy (including psychoanalysis, CBT, DBT, ACT, group psychotherapy, couples therapy, family therapy etc), or neuromodulation. Some specialize predominantly or exclusively with certain patient populations such as eating disorders, PTSD, somatoform disorders, LGBTQ, perinatal, psycho-oncology etc.

I would encourage you to try to get a taste of some different aspects of psych beyond just inpatient and outpatient (even if it's just a day here and there). At the med school I worked at, we had a list of attendings who would allow students to shadow for as little as an hour or as long as a day, and had some mini electives (e.g. a week) for students to get more exposure. Contact your director of medical student education in psychiatry to see if they can assist.

There is a difference between being a people pleaser (which is most physicians) and being a doormat. You are going to struggle to be effective in any field except running a pill mill if you really struggle with this. You will also get taken advantage of by your colleagues and superiors. That said, most students and even junior residents will struggle with setting limits and saying "no" to patients. It is a skill you develop over time. Worst case scenario, you get shot. Best case, you could really transform someone's life.

RE: ADHD, while this will always be a common presentation for outpatient psych, it is also one of the latest in a long line of fads in psychiatry. 40 years ago people thought they had multiple personalities, 20 yrs ago everyone thought they had bipolar, now it's ADHD. There will be some other diagnosis in vogue at some point. And it's exactly the same patients each time round. The only difference is the fads are increasingly influenced by late stage capitalism (though people were claiming this over 40 years ago too!)

I would argue that most psychiatry programs teach this skill better than any other subspecialty. I have a social circle that is almost exclusively other doctors, but very few psychiatrists, and I am consistently amazed at how little discussion there was about how to say no to patients. We got entire lecture series on the topic and any psychodynamic therapy supervisor is going to touch on the topic almost inevitably along with all the work you do inpatient with involuntary admissions (which is admittedly a very different feel that saying no in the outpatient realm).

That is all to say to OP that if you want to develop skills to be an effective human being instead of a doormat and are open to doing the work, psychiatry is going to be a good fit. You may still prefer something like palliative care with your current persona, the only real question is if you are open to change. I am a markedly different person now than when I was in the middle of med school and so very glad for it.

 

[Candidate2017]

On my psych rotations I found a lot of my patient interactions were more paternalistic (involuntary treatment inpatient, refusing benzos or stimulants outpatient), and the frequency of conflict and power-struggles with patients was draining sometimes. I'm sure one reason for this is just that my knowledge base / ability to explain things to patients is stronger in IM > psych at this stage of my training, which I suspect will get better in psych residency.

This is a typical day for the vast majority of psychiatrists.

And no, it is not your knowledge base. You're dealing with people who want substances, people who are difficult (i.e., personality disordered), and/or people who are incapable of comprehending you because they have actual broken minds.

Your psych rotation sounds less than ideal and not typical of what most students get, but is unfortunately more reflective of wider practice.

Actually, it's quite an ideal psych rotation, as psych attendings tend to shield students from the realities of psychiatric practice, which is a disservice. OP is not getting informed consent into what a career in psychiatry entails. Most other rotations, unlike psych, do provide a fairly good glimpse into the day to day work as an attending in that specialty.

The good news is that psychiatry has a wide variety of practice settings and specialties so one can find their niche. Psychiatrists can work in private practice, clinics, general hospitals, state hospitals, academics, community mental health, homeless outreach, prisons, jails, schools, colleges, ICE detention, courts, residential treatment programs etc.

The bad news is OP will still have to deal with the same issues related to conflict and power struggle in many of these niches. Sure, you can possibly carve out a niche where you don't have to deal with these things, but it won't be set up for you straight out of residency. Whereas you know exactly what to expect from IM or an IM specialty and can walk into your preferred practice setting from day 1.

 

[Stagg737]

Sorry in advance for the length - my main question here is really: 1) do you see 'people-pleaser' types, or people who feel conflicted about involuntary treatment really struggle to succeed & feel happy as psychiatrists?

People pleaser types can struggle heavily and get too emotionally entrenched with their patients and outcomes. It can definitely be difficult to separate the patient not improving and/or complaining that you're not treating them the way they want with the objectivity of doing what is actually helpful for them and the reality that some patients just aren't going to thrive.

The bolded often comes from either a lack of understanding of why we have involuntary statutes or seeing a system that is isn't utilizing them properly/failing patients. The point of an involuntary admission is to ensure that the patient does not do harm (direct or indirect) to themselves or others because of a cognitive impairment causing them to make decisions that they would not want. It's actually a form of preserving patient autonomy and when done correctly most patients will later be glad they received treatment.

There are rare cases where an appropriate invol does not align with what the patient would want at baseline and the invol is to protect others or provide dignity/humanity to patients (chronically psychotic patient keeps trying to kill people because they think they're demons, keeps trying to cut off their limbs because they believe they sinned, etc). I can see why this would be difficult as it is difficult for many of us, but is unfortunately sometimes necessary to prevent greater harm.

I'm a bit of a people-pleaser/doormat by nature, not naturally very good at saying 'no' or refusing patients' wishes, and it wears on me.

This is something you should address regardless of what field of medicine you enter, but it's good that you recognize this early. Boundaries are essential to good patient care, maybe more so in psychiatry than any other field. Some docs have to keep stronger boundaries than others to make sure they're practicing the best they can and that's okay. If this is something that is really distressing for you and that you can't overcome, then psych might not be a good fit. Not trying to steer you away, just something to keep exploring as you decide what road you want to pursue.

 

[clausewitz2]

Sorry in advance for the length - my main question here is really: 1) do you see 'people-pleaser' types, or people who feel conflicted about involuntary treatment really struggle to succeed & feel happy as psychiatrists?

I probably score lower on trait Agreeableness than the average person, but after residency I deliberately avoided ever working in a setting where a bulk of my work was going to be with patients who did not choose or want to work with me on some level. It is absolutely possible to do this. I also am someone raised in a culture that strongly discouraged direct interpersonal conflict and specialized in elaborate ways to avoid saying no to people. Over time and training I have gotten way more comfortable doing this in a transparent way. If I could shake the core belief of "if someone straight up asks me for something directly I am more or less required to say 'yes'", I think you can probably do so too.

I think the main reason I've felt some pull away from psych relates to the ways it's hard to experience (3) as a med student in psych, vs. easier to experience as a med student in IM. On my IM rotation I had lots of opportunities to practice patient education, counseling and shared-decision-making. On my psych rotations I found a lot of my patient interactions were more paternalistic (involuntary treatment inpatient, refusing benzos or stimulants outpatient), and the frequency of conflict and power-struggles with patients was draining sometimes. I'm sure one reason for this is just that my knowledge base / ability to explain things to patients is stronger in IM > psych at this stage of my training, which I suspect will get better in psych residency. The thing that concerns me more is that there's a personality aspect - I'm a bit of a people-pleaser/doormat by nature, not naturally very good at saying 'no' or refusing patients' wishes, and it wears on me. I love when I can reach a place of mutual understanding with patients about their condition, and when patients' poor insight is part of their condition, it's hard to feel like I can understand or respect their wishes. I realize these will be issues in IM too- I'm just wondering if they're liable to cause more friction in psych.

You can have plenty of patients in IM who are doing just fine at navigating their lives, having fulfilling relationships, pursuing their values etc but who draw a bad hand and so need the care of medical specialists regardless. Nobody comes to a psychiatrist who is already doing all of these things. They don't need a psychiatrist.

While you do have to learn to say "no" in psychiatry you don't have to get pulled into struggles. I think anyone in mental health with any meaningful clinical experience will agree with the proposition that if you find yourself arguing with your patient, you're done, you lose, just stop. It will never lead to any productive outcome. You learn to apply some DEARMAN-adjacent skills of becoming comfortable clearly saying no to something without getting diverted into arguing about justification or trying to convince the other person that you are blameless in your refusal. You can turn someone down without getting their buy-in.

The other / more minor hesitations I have about psych are more practical. I've gotten the sense that '?adult ADHD' referrals are an increasingly big part of outpatient psych, and while I'm happy to do adult ADHD evaluation & treatment sometimes, I know I don't want it to be the majority of what I do every day. Is this an issue for any of you, and how avoidable is it? (I don't mean to diminish the importance of ADHD with this / sorry if it comes off as flippant).

If you really want to dramatically reduce the number of adult ADHD evals you get on the regular you can just advertise as part of your practice that you don't prescribe stimulants to new patients. It's not my approach but it would be effective and if you're taking insurance in most places as an OP psychiatrist you'll still be fine panel-wise.

 

[comp1]

First and foremost, good on you for the introspection. Recognition is first step, next step is some therapy to address the issue because you're going to burn out right quick in psych or IM otherwise. Maybe for different reasons, but you still will. I've never actually met anyone who regretted choosing psych? I have met some people who regretted IM, but I think that might be my bias. Combined is a bad idea unless you have some idea already of what you want to do with it, otherwise you will end up just practicing psych while also losing a year of income. I have known several psychiatrists who really bristle against the paternalism in psych. Fortunately as others have said, you can design your practice. There are certain limits, such as a patient telling you they plan to kill themselves tonight, the standard of care there really is paternalism, but if you just can't handle telling people who believe all food is poisoned that they do indeed have to take medications, you can mostly filter those patients out if you're going to just do outpatient (which the vast majority of psychiatrists do).

 

[slowthai]

I've never actually met anyone who regretted choosing psych? I have met some people who regretted IM, but I think that might be my bias.

Lol, I've met multiple that regret/dislike IM as well. None for psych.

 

[Stagg737]

I've never actually met anyone who regretted choosing psych? I have met some people who regretted IM, but I think that might be my bias.

Lol, I've met multiple that regret/dislike IM as well. None for psych.

I've met a few who regretted psych. However, most of the time it's not so much that they specifically regretted psych, it was that they couldn't match into their desired field and I think regretted medicine in general because they didn't get what they wanted. I can only think of one person who legit regretted psych, but they were basically just chasing money/lifestyle. Agree that it's rare for someone who actually enjoys it to regret it though. We're a flexible enough field that once you're an attending you can find a setting and patient population that you enjoy.

 

[comp1]

The literal highest paid state employee in CA was a prison psychiatrist who was on 24/7 call for most of a year and made $750k. If you want to chase money, you definitely can.

 

[Ludwig2000]

I’m a people pleaser type and my current job as an inpatient attending is a nightmare.

Other fields of medicine are MUCH more about being allied with the patient against an illness. A LOT of psych is a patient and their illness (or personality, or addictive behavior) being allied against you.

I would seriously consider something like IM >> Heme/Onc if I were you.

 

[Attending1985]

There will be some other diagnosis in vogue at some point. And it's exactly the same patients each time round.

This is so spot on. Care to share your description of these patients?

 

[Mad Jack]

This is so spot on. Care to share your description of these patients?

The perpetually vaguely distressed, often with a trauma and/or substance use history, who sense that something is wrong and that answer must be the Hot New Diagnosis. The answer always seems to be the thing that will either provide a controlled substance or a disorder around which they can form an identity instead of getting to the heart of what their actual issue is, which would require hard work and a lot of therapy.

 

[Merovinge]

I’m a people pleaser type and my current job as an inpatient attending is a nightmare.

Other fields of medicine are MUCH more about being allied with the patient against an illness. A LOT of psych is a patient and their illness (or personality, or addictive behavior) being allied against you.

I would seriously consider something like IM >> Heme/Onc if I were you.

WTF are you doing working IP then? That's like saying you are a great athlete, 5'6" tall and only willing to play basketball...

 

[comp1]

The only way you can do inpatient or CL as a people pleaser is to reframe your view of who your client is because it's just not going to be able to be the identified patient. You can reframe it as nursing, social workers, the medical team or even society at large.

 

[Stagg737]

The only way you can do inpatient or CL as a people pleaser is to reframe your view of who your client is because it's just not going to be able to be the identified patient. You can reframe it as nursing, social workers, the medical team or even society at large.

Eh, I don't completely agree. I'm a people pleaser and I love C/L and inpatient. If you're like that you have to come to terms that with some patients you're just going to have to keep hard boundaries and understand that actually helping them will often mean no pleasing them in those settings. Plenty of patients are really grateful though, so more about taking those wins and letting the other ones go.

 

[mistafab]

Unchecked people pleasing can make life stressful when on inpatient and CL settings.

However, long term, unchecked people pleasing can cause significantly more harm to your patients in the outpatient setting.

Both scenarios can be greatly prevented (or ameliorated) through good supervision. Psychiatry is not about being perfect, it is about being aware of what you bring with you in the patient encounter - and learning to adapt to make the interaction more therapeutic for the patient. It is a skill, and takes practice and mentorship to develop.

As for concerns about people who end up not liking psych - I have met one. He is a great thinker and good physician. However, he in general was never a fan of listening to people, and came into things more like a procedural mindset. He found it unsatisfying though he decided there was enough of what he liked in psych to continue through residency with plan to do a fellowship and tailor practice away from more common psych settings (less inpatient/outpatient, more CL/sleep/pain).

I know another who somewhat regretted psych (regretted not dual boarding psych/IM). She felt she never got the satisfaction from psych of medical problem solving. For her, psych wasn't "medical enough" to hit that feeling she wanted to get in her day to day. She of course finds C/L and geriatrics more interesting as a result, but wished she had done a dual board. She's still in residency so i'm not sure if that feeling will continue later.

 

[brosa]

Some days I regret psych. A few times I have day dreamed about being an oncologist, with patients running to be able to see me, taking notes of the medication I am prescribing and being so appreciative I am prescribing something. Not everyday, but inpatient does give me some burn out when most of your patients are just going to be discharged, do meth, and come back.

Other days that I regret psych are regarding many job offers that I get, that are not so good. The solid ones are in the Midwest and California. Although I believe this feeling will be temporary until I open my practice, then it should get better.

At the end of the day, it is common for the grass to at least appear to be greener at the other side. I am sure other specialities feel the same way and sometimes wonder about us lol

 

[comp1]

Ugh, oncology being the greener grass? No thank you.

 

[Merovinge]

Ugh, oncology being the greener grass? No thank you.

You don't like making people really sick and then still having them die of that illness while spending hundreds of thousands to millions of dollars in the process!?

But seriously, tons of respect to all onc folk. Med onc, surg onc, rad onc, bless all of you. Also, all the bazillion researchers that are making demonstrable gains against cancer.

 

[brosa]

Ugh, oncology being the greener grass? No thank you.

When you spend everyday arguing with patients that they should take their meds, explaining why they can't leave the hospital, and being hated, you kinda wonder about the opposite. Imagina patients rushing toward you in a field full of yellow flowers, paying close attention to your treatment options, and being thankful you are there lol

Ofc this only goes for inpatient, outpatient population wants to be there and they are glad to see you.

 

[Stagg737]

When you spend everyday arguing with patients that they should take their meds, explaining why they can't leave the hospital, and being hated, you kinda wonder about the opposite. Imagina patients rushing toward you in a field full of yellow flowers, paying close attention to your treatment options, and being thankful you are there lol

Ofc this only goes for inpatient, outpatient population wants to be there and they are glad to see you.

Was about to say, as much as I hate outpatient I do have a fair number of patients who really do work to get better and are incredibly grateful I’m there for them. Inpatient you do get a lot more of that, but I still had plenty of inpatient who were grateful to be getting care when I did that too (and not just the ones wanting a roof and some meals for a few nights).

 

[Medicine Mamba]

PGY-1 here. What do you guys hate so much about outpatient?

 

[HemeOncHopeful19]

Imagine patients (and their 5 family members crammed into your tiny room plus their second cousin on the phone who is an expert nurse in Idaho and has a list of questions) rushing toward you in a field full of yellow flowers (which coincidentally they read online these specific flowers are a secret anti-cancer flower that big pharma doesn’t want you to know about) paying close attention to your treatment options (which often you get one shot to cure them so hope you recommend the right one), and being thankful you (and your triage nurse) are there (24hrs a day 7 days a week) lol

 

[J ROD]

PGY-1 here. What do you guys hate so much about outpatient?

assembly line of patients. one after another. Having to deal with benzodiazepines and arguing over it. Along with Adult ADHD because I am now 40 and my memory is not as good. I would also argue the new fad is ASD and ADHD is still prominent. But usually have both. Bipolar but actually Borderline. Border Polar ? (patent pending)

 

[Stagg737]

PGY-1 here. What do you guys hate so much about outpatient?

Just a few of the things I hate (not necessarily unique to outpatient, but more prevalent)

1. Fixed time per patient. Not really much flexibility if you want to take extra time with them without getting behind unless the next patient no shows.

2. Drug seeking. Certainly happens in other settings, but in other settings I get to discharge them. Outpatient they usually hang around.

3. The inbox. Can be an absolute nightmare, especially if you treat a good number of cluster B patients.

4. The worried well. Opposite of number 3 there are plenty of patients who have “anxiety” or “depression” and want a pill to fix it. Sometimes they’re fine and easy to work with, but I’ve found they’re often quite entitled and have underlying personality traits that are problematic.

5. Along those lines, the unmotivated patients and resistance to therapy. Sorry, lexapro isn’t fixing that disconnect you’re feeling from your spouse or that your kids are rebelling, you need to talk to someone. We can throw med non-compliance in here as well.

6. On the opposite side, severely/chronically ill patients. Honestly, I really enjoyed this population at the CMHC I worked at in residency, but in clinics that don’t have extensive resources (CMs, ACT teams, nurses to administer LAIs, etc) these patients add a lot of gray hairs to my head. Especially the ones who get legitimately suicidal very quickly. I sometimes turn these patients down in my consult clinic and tell the PCP they need a long-term clinic with more resources, but many outpatient clinics will take them.

7. The physical and social isolation/stagnancy. I enjoy getting up, walking around, not being in one chair all day, and working in a team (hence part of my love for C/L). The idea of sitting in one or two offices all day, one on one with patients, with no other staff to work with just sucks to me. If that’s your jam then great, but if you like working in a team outpatient can feel very lonely.

8. Lack of medical care. This is something that most psychiatrists probably see as a plus, but I went to med school because I enjoy medicine. On C/L, I have to keep my medical knowledge sharp and understand stuff outside of just psychiatry. I treat a lot of medical/medication induced issues and MH d/t GMCs. I know a lot of OP psychiatrists who are scared to start metformin or don’t even think about how other medications are impacting care. I loathe that, but to each their own.

9. The self-diagnosed (as already mentioned above). The patients who come in and are sure they have xyz disorder and can’t be swayed otherwise. I actually don’t mind if they come in saying, “I think I might have X” as long as they’re willing to consider other options and work with me. Those just looking for a label or want a specific drug are usually quite unpleasant to work with.

I’m sure there’s more, but those are some of the big ones. I’ve thought about making an “all the things that suck about outpatient” thread like the inpatient one we had, but may or may not get around to it.

 

[Merovinge]

Just a few of the things I hate (not necessarily unique to outpatient, but more prevalent)

1. Fixed time per patient. Not really much flexibility if you want to take extra time with them without getting behind unless the next patient no shows.

2. Drug seeking. Certainly happens in other settings, but in other settings I get to discharge them. Outpatient they usually hang around.

3. The inbox. Can be an absolute nightmare, especially if you treat a good number of cluster B patients.

4. The worried well. Opposite of number 3 there are plenty of patients who have “anxiety” or “depression” and want a pill to fix it. Sometimes they’re fine and easy to work with, but I’ve found they’re often quite entitled and have underlying personality traits that are problematic.

5. Along those lines, the unmotivated patients and resistance to therapy. Sorry, lexapro isn’t fixing that disconnect you’re feeling from your spouse or that your kids are rebelling, you need to talk to someone. We can throw med non-compliance in here as well.

6. On the opposite side, severely/chronically ill patients. Honestly, I really enjoyed this population at the CMHC I worked at in residency, but in clinics that don’t have extensive resources (CMs, ACT teams, nurses to administer LAIs, etc) these patients add a lot of gray hairs to my head. Especially the ones who get legitimately suicidal very quickly. I sometimes turn these patients down in my consult clinic and tell the PCP they need a long-term clinic with more resources, but many outpatient clinics will take them.

7. The physical and social isolation/stagnancy. I enjoy getting up, walking around, not being in one chair all day, and working in a team (hence part of my love for C/L). The idea of sitting in one or two offices all day, one on one with patients, with no other staff to work with just sucks to me. If that’s your jam then great, but if you like working in a team outpatient can feel very lonely.

8. Lack of medical care. This is something that most psychiatrists probably see as a plus, but I went to med school because I enjoy medicine. On C/L, I have to keep my medical knowledge sharp and understand stuff outside of just psychiatry. I treat a lot of medical/medication induced issues and MH d/t GMCs. I know a lot of OP psychiatrists who are scared to start metformin or don’t even think about how other medications are impacting care. I loathe that, but to each their own.

9. The self-diagnosed (as already mentioned above). The patients who come in and are sure they have xyz disorder and can’t be swayed otherwise. I actually don’t mind if they come in saying, “I think I might have X” as long as they’re willing to consider other options and work with me. Those just looking for a label or want a specific drug are usually quite unpleasant to work with.

I’m sure there’s more, but those are some of the big ones. I’ve thought about making an “all the things that suck about outpatient” thread like the inpatient one we had, but may or may not get around to it.

It's all about modeling in residency. If you have awesome C/L and neuropsychiatry it will hopefully shift your perspective. Coming out of med school I was like "oh all general medical knowledge is useless", thankfully I woke up in residency and care a lot about all things medical (and surgical). Wish I had paid more attention in some rotations/classes in med school though.

Please please get the best foundational training you can in all of medicine to any med student or trainee, it will inevitably save or markedly improve someone's life during your career.

 

[vanfanal]

Some days I regret psych. A few times I have day dreamed about being an oncologist, with patients running to be able to see me, taking notes of the medication I am prescribing and being so appreciative I am prescribing something. Not everyday, but inpatient does give me some burn out when most of your patients are just going to be discharged, do meth, and come back.

Other days that I regret psych are regarding many job offers that I get, that are not so good. The solid ones are in the Midwest and California. Although I believe this feeling will be temporary until I open my practice, then it should get better.

At the end of the day, it is common for the grass to at least appear to be greener at the other side. I am sure other specialities feel the same way and sometimes wonder about us lol

Or an opt otho clinic. People lined up, WANTING to see you. Quick visits. Ancillary staff to make things efficient. Ughh...really having some off days with psych rn when pt show up 15mins late and just want to talk about nothing relevant to the visit.

 

[clausewitz2]

Or an opt otho clinic. People lined up, WANTING to see you. Quick visits. Ancillary staff to make things efficient. Ughh...really having some off days with psych rn when pt show up 15mins late and just want to talk about nothing relevant to the visit.

And this is when you bring things to a close as close to the scheduled time as possible and make another appointment for them sooner than usual because clearly there is so much to talk about.

This is more tolerable when you have control of your own scheduling and also are getting reimbursed directly for encounters instead of being on salary, I recognize.

 

[calvinhobbes]

assembly line of patients. one after another. Having to deal with benzodiazepines and arguing over it. Along with Adult ADHD because I am now 40 and my memory is not as good. I would also argue the new fad is ASD and ADHD is still prominent. But usually have both. Bipolar but actually Borderline. Border Polar ? (patent pending)

These are the easiest patients for me. Because I tell them how it is and that I’m the wrong doctor for them, and they can find someone else. Border polar is awesome haha 🙂

 

[Merovinge]

Or an opt otho clinic. People lined up, WANTING to see you. Quick visits. Ancillary staff to make things efficient. Ughh...really having some off days with psych rn when pt show up 15mins late and just want to talk about nothing relevant to the visit.

Sure, pros are reimbursement, less emotional entanglement, but cons are that seeing 40 pts a day is pretty dehumanizing where you see a person as a widget with a problem. I like actually knowing all my patient's as people. Absolutely nothing wrong with derm/surgery clinics but it's very different than primary care/psychiatry and even many medical subspecialties.