Rising M4 - optimizing prep for inpatient psych sub-I, post research year

[trillianMcMillan]

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Hi all - I’d appreciate perspective from residents/attendings on how best to structure my early M4 schedule.

I’m a rising M4 returning from a research year between M3-M4. Due to institutional limitations, I wasn’t able to do clinical work during that year, so I’ll be re-entering rotations this summer. Prior to the research year, I completed a medicine sub-I and a few electives.

My current schedule:

• Early June: Inpatient Addiction Psych
• June–July: Medicine Consults
• July–Aug: Inpatient Psych AI
• Aug–Sept: C/L Psych

My goal is to be fully ramped up by the time I start my inpatient psych AI, particularly in:

• Inpatient management and daily workflow
• Efficiency with presentations
• Diagnostic formulation and interviewing
• Operating at near-intern level responsibility

I’m considering replacing Medicine Consults with something more psychiatry-focused to maximize direct prep for the AI. Options available to me include:

1. Away rotation in inpatient psychiatry
2. Independently designed psychiatry elective (would require arranging a sponsor/site) - could be inpatient or outpatient
3. Neurology (inpatient or outpatient)
4. A second emergency psychiatry elective at a different hospital

For those who supervise sub-Is:
Would maintaining a medicine consults month be more valuable for long-term training, or would additional inpatient psych exposure be more impactful for AI performance?

Appreciate any insight, especially from those who’ve seen students return after time away from clinical work.

 

[comp1]

Are all of these options at the same site/hospital? As an attending, the most helpful thing from medical students is for them to be exceedingly familiar with the flow and RESOURCES of a given hospital/system from the start, including the EMR. Anyone can check off boxes from the DSM and pick an antipsychotic/SSRI. That is not super interesting to me. What is impressive is actually being of assistance with real discharge planning and it shows attention to the whole person fact that most of inpatient psychiatry is about selecting and connecting to services, not picking a med. An away rotation or anything at a different hospital will definitely not help with that, but if you want to match at that away site over your home site, you probably should still do it. How much medicine you do really depends on the structure of the inpatient psych unit. Do psychiatrists manage most medical conditions themselves, eg diabetes and HTN? If so, you want more medicine. If they don't, you don't. Most VAs have psychiatrists manage those conditions, most private psych hospitals do not. Academic hospitals are in the middle. Learn about yours. I am always more impressed by a medical student making a reasonable BP med choice than an antipsychotic. Believe me, the psych meds get really boring really fast and you will be unlikely to make any sort of impression with psych attendings or even residents by being good at them, only if you are extraordinarily bad. Most choices are "right" in terms of psych meds and only a few are wrong. You do not need more neuro time, full stop. Also, um, you're putting far too much thought into this. It'll be fine.

 

[mistafab]

Main thing would be if possible (or not already done) to make sure to complete step 2 CK before your psychiatry sub I. You don't want to be worried about an upcoming test while trying to shine on a sub-I.

I think medicine consults or psych away rotation are both good options to prepare. The inpatient addiction psych work will really help you get back into the workflow of psych-specific work. Make sure you nail down and have an excellent MSE and can finish your notes timely/effectively before your Sub I. Get as much feedback as possible during your inpatient addiction month and specifically ask if they can go "line by line" with you on your note a few times a week or a note a day with you to improve your notes.

Your notes are equivalent to your thinking, so improving those will make you a more effective psych communicator come time for your Sub I. Start your rotations by saying "I'm wanting to go into psych, so please give me as much feedback as possible" when showing up to your addiction month. Show up early, work hard, take on as much work as possible, and you'll do well come time for your sub-I. Can you do daily notes on at least 2 patients a day? What about 4? Can you propose a basic assessment and workable plan? See what is expected of interns on that rotation and try to get to that level.

From my perspective as an attending who teaches med students and residents -> working hard and being coachable are by far the most important factors. I'm the expert, not you - so don't worry about being perfect. Just show up (ON TIME), be ready to work, and willing to learn.

 

[Taddy Mason]

Just curious - when you say “inpatient addiction” is that an inpatient substance use unit or addiction C/L? I run an addiction C/L service that’s a busy teaching service and we regularly get students who are confused and think we’re a primary service or true “inpatient” addiction service (i.e., patients admitted solely for substance use issues).

 

[trillianMcMillan]

Are all of these options at the same site/hospital? As an attending, the most helpful thing from medical students is for them to be exceedingly familiar with the flow and RESOURCES of a given hospital/system from the start, including the EMR. Anyone can check off boxes from the DSM and pick an antipsychotic/SSRI. That is not super interesting to me. What is impressive is actually being of assistance with real discharge planning and it shows attention to the whole person fact that most of inpatient psychiatry is about selecting and connecting to services, not picking a med. An away rotation or anything at a different hospital will definitely not help with that, but if you want to match at that away site over your home site, you probably should still do it. How much medicine you do really depends on the structure of the inpatient psych unit. Do psychiatrists manage most medical conditions themselves, eg diabetes and HTN? If so, you want more medicine. If they don't, you don't. Most VAs have psychiatrists manage those conditions, most private psych hospitals do not. Academic hospitals are in the middle. Learn about yours. I am always more impressed by a medical student making a reasonable BP med choice than an antipsychotic. Believe me, the psych meds get really boring really fast and you will be unlikely to make any sort of impression with psych attendings or even residents by being good at them, only if you are extraordinarily bad. Most choices are "right" in terms of psych meds and only a few are wrong. You do not need more neuro time, full stop. Also, um, you're putting far too much thought into this. It'll be fine.

I appreciate the point about sites -- luckily I'll most likely be able to do all of my rotations (any of the options) at the same site, which is also the site where I did most of my clinical rotations. Helpful to hear your thoughts on the value of medical knowledge as well- and yes true I'm sure I'm overthinking this 😅 thanks for the insights!

 

[trillianMcMillan]

Main thing would be if possible (or not already done) to make sure to complete step 2 CK before your psychiatry sub I. You don't want to be worried about an upcoming test while trying to shine on a sub-I.

I think medicine consults or psych away rotation are both good options to prepare. The inpatient addiction psych work will really help you get back into the workflow of psych-specific work. Make sure you nail down and have an excellent MSE and can finish your notes timely/effectively before your Sub I. Get as much feedback as possible during your inpatient addiction month and specifically ask if they can go "line by line" with you on your note a few times a week or a note a day with you to improve your notes.

Your notes are equivalent to your thinking, so improving those will make you a more effective psych communicator come time for your Sub I. Start your rotations by saying "I'm wanting to go into psych, so please give me as much feedback as possible" when showing up to your addiction month. Show up early, work hard, take on as much work as possible, and you'll do well come time for your sub-I. Can you do daily notes on at least 2 patients a day? What about 4? Can you propose a basic assessment and workable plan? See what is expected of interns on that rotation and try to get to that level.

From my perspective as an attending who teaches med students and residents -> working hard and being coachable are by far the most important factors. I'm the expert, not you - so don't worry about being perfect. Just show up (ON TIME), be ready to work, and willing to learn.

Thankfully was able to take Step 2 before going on leave, very glad for that. And I really appreciate this advice, definitely helpful- thank you!

 

[trillianMcMillan]

Just curious - when you say “inpatient addiction” is that an inpatient substance use unit or addiction C/L? I run an addiction C/L service that’s a busy teaching service and we regularly get students who are confused and think we’re a primary service or true “inpatient” addiction service (i.e., patients admitted solely for substance use issues).

I'm pretty certain it'll be at a residential substance use treatment facility affiliated with our academic hospital (they don't tell us our site until closer to the rotation, but that's where my peers did theirs)-- I appreciate the point, definitely a good thing to check