Scared, stressed intern...HELP!

[mamabear]

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I am reluctant to post this but feel like I deperately need advice and don't know who to turn to right now. I am a psych intern and have been having a fairly good intern year thus far. More recently, though, things have taken a turn for the worst. The other interns and myself have found ourselves experiencing a nearly doubling of our workload recently (in terms of patients to see inpatient). We can't keep up, we don't know our patients well, we aren't learning...we rush all the time. We don't get good teaching now because we are having faculty problems and turnover. So those are some of the stressors but more recently something else has made everything feel worse, and this is especially why I am writing to fellow psychiatrists for help.

We have, in the past week or so, admitted several fairly aggressive, violent patients to the lock down unit. Most are schizophrenic, but not all. They bang on walls a lot, yell often, and follow me around too closely when I make rounds on my own. I feel like I don't have control over the situation, and if one were to attack me, I wouldn't know what to do. I feel scared and I don't want to. This makes me hate my job, and prior to this, I was loving the work and actually looking forward to the next day. Now I don't want to go, I hate my job, and I question even whether or not I want to do psychiatry (I am sure I do given I don't have to be fearful of such patients).

How can I cope with this? Is this just an adjustment reaction, common among psych interns, and it may improve with time? What can I do to keep myself safer? How do I handle these patients?

I know this is a lot to ask but I need advice. I hate the way I feel.

Thank you.

 

[Doc Samson]

Why the doubling? More patients coming into the hospital, or an actual expansion of the unit? If it's the latter, then you have a good case to ask your program to make some cases "non-teaching."
In terms of the fear: always, always, ALWAYS trust your gut. If you feel scared it's for a reason (i.e. wandering around a unit by yourself with aggressive patients). A short-term answer is to round with someone else, or set up shop in an interview room and have he nurses bring the patients to you. Don't ever feel ashamed for having a limbic response, respect it for what it is - an early warning system.

 

[mamabear]

We have a doubling of patient load because 2 out of 5 of our residents rotated off service and now it's just 3 of us for several months doing the work of 5 interns.

Part of my problem with the aggressive patients are actually other doc's patients that follow me around and ask me questions while I am trying to see my patients. I don't know how to appropriately get rid of them--maybe like you said, I need to get a room to bring my patient to.

Thank you for input.

 

[PsychMD2100]

You can also get a panic button to wear on a string around your neck or on your white coat. Many psych wards have such a system. Do your wards also have panic buttons on the walls of each room? Typically, sitting closest to the door and within arm's reach of the panic button is a good way to go.

 

[OldPsychDoc]

We have a doubling of patient load because 2 out of 5 of our residents rotated off service and now it's just 3 of us for several months doing the work of 5 interns.

Part of my problem with the aggressive patients are actually other doc's patients that follow me around and ask me questions while I am trying to see my patients. I don't know how to appropriately get rid of them--maybe like you said, I need to get a room to bring my patient to.

Thank you for input.

What's bothering me about this is that it sounds like for one reason or another this milieu has gotten out of control, and you've got some psychotic/antisocial patients picking up that 1) the doctors aren't confident, 2) the nurses won't back the young doctors up, and 3) no one is really in charge. I've seen this happen other times in situations where a normally quiet depression/gero ward suddenly gets a bunch of young addicted antisocials on board for no better reason than that's what shows up in the ER for a few days. It can be compounded by things like nursing morale, attendings distracted by department politics, etc. Meanwhile you're caught in the middle, and rightly feeling threatened.

Is there someone you can share your concerns with? A senior nurse (heck, even a veteran NA!) might be your best resource, as he/she has seen these cycles before, and can help you and your intern colleagues learn to project confidence and set appropriate limits with patients on the ward. Above all, pay attention to your own safety, as your colleagues above have said. Don't sweat the learning--next year you'll look back on this and see that you really were learning all along!

 

[whopper]

"You can also get a panic button to wear on a string around your neck or on your white coat."

Make sure if a necklace is worn, that it is easily breakable or it can be used to choke you.

Remember, the ACGME has clear guidelines on how many patients you are allowed to see. The program cannot simply use you as cheap labor up until a certain degree. If you feel you are seeing too many patients and it is over the ACGME mandates, the program is obligated to decrease the load to the maximum limits.

Another thing is how much safety is your hospital devoting to you as a resident. In my own hospital, I never once felt in real danger. Security is there within 30 seconds. The staff know when to press the button. Is that the case for you? Is the hospital fulfilling its own end to keep you safe? If not, you should bring it up..and if the hospital isn't doing what its supposed to be doing--should you get injured, you got a major lawsuit you could put against them.

Talk about this situation with your fellow residents. Maybe you're overreacting, maybe you're not. Maybe the place is safer than you think it is, maybe its not. If other residents are feeling the same way you are, you as a group should be vocal on this issue.

 

[Solideliquid]

If several patients are aggitated, following you around, banging on the walls and so on, look at their meds. Maybe someone needs a little more sleeping medicine?

I also very much agree with limit setting and boundries. On the VA ward patients usually accost me asking when they can leave, that they want this or that and they are not my patients. I firmly tell them I am not their doctor and they have to wait to see their doctor. If they wish they can ask the nurse to page their doctor. Be firm. Don't go off down the hall by yourself where no one can hear you calling for help, take a burly med student or ask a nurse to accompany you.

I'm sorry you are having a bad time, the interns in my program (myself included) are all feeling the burnout of call, and the hours. Things should never get so bad that you fear coming into work, talk to your PD.

 

[RustNeverSleeps]

I don't have any specific advice, but just wanted to post that I feel for you and wish you the best. One question I did have: is your unit the appropriate place for these violent patients, or are they just getting stuck there? At my school, the hospitals' psych wards do not have the staff to accomodate very violent patients, so they are sent to the state psych hospital, which does have the appropriate staff resources for such patients. If your ward is supposed to house these kinds of patients, it seems like improvements need to be made.

 

[sga430]

btw, what program r u in?? 😕

chances are u aren't gonna answer this query. or perhaps u can pm me. i am on the interview trail and there is a 1 in 4 chance i have interviewed there.

 

[mamabear]

I want to thank you all for your responses and advice. I think OPD really hit on one of the key ideas: we are lacking in confidence and we don't have nursing staff to back us up very well. And the morale among attendings is poor right now because there is some current turnover, current attendings leaving and new ones about to come on board. We only have panic buttons in our admissions interview rooms on an entirely different floor. I've never heard of panic buttons to wear around the neck. I was even thinking the other day that maybe carrying pepper spray in my pocket would be a decent idea. I just would like to be able to protect myself. I know that's not the answer.

I did have one particular antisocial patient this week, a 27 year old, who had been called paranoid schizophrenic for years by the state system. He'd been in state hospitals multiple times--he gets out and then goes off meds and is brought back by the police usually. This time he was somehow able to purchase a gun and shot his own dog (in the leg, didn't kill the animal) and then shot at his walls in his mother's home. The police brought him to us. He's a cold fish. I don't like him at all and really would rather he be in prison. Today the state hospital agreed to take him as a transfer, which was a relief to me. So in response to an earlier post, fortunately this patient was sent to a more appropriate facility but all them aren't. The other intern and myself went to our chief resident this week and basically demanded improvements with regard to the work load. She told us she's bringing the concerns to the PD and expects (no promises) that they will lower our cap. So I will keep my fingers crossed. Life ain't good right now.

I feel better reading all the responses. And I think talking with an experienced nurse is an excellent idea. One that I will try soon.

Thanks again.

MB

 

[50960]

This is a toxic environment. I teach in a FP residency program so have a clue, and I have several psychiatrists I consult with. I have no advice as I know bailing on a residency is bad news, but perhaps you could locate a recently minted psych or a 3rd year to help you get through this....... You need to be safe.

 

[whopper]

I've never heard of panic buttons to wear around the neck. I was even thinking the other day that maybe carrying pepper spray in my pocket would be a decent idea.

Again, and at least this is so in NJ, but wearing anything around your neck in an involuntary psyche ward mandates that any band be breakable so that if a patient tries to choke you, the necklace will snap. For that reason, the residents in my program don't have to wear ties.

In several states, macing a patient is considered a violation of your Hippocratic Oath, so be careful. In NJ, you are allowed to defend yourself should a patient attack you by attacking back, but it can only match the force given to you--e.g. he hits you, then you are allowed to hit him back, and it must be done with the intention of only defending yourself and hoping to get away, nothing else.

You need to be careful with stuff like this. Some programs don't tell you what the rules are ahead of time, and when you break them (Even with no bad intentions) they can jump on you.

 

[Someguy2007]

If I may ask, what program is this MB? The reason I ask is I am applying to psych program's in TX.

 

[sga430]

another option of last resort is to switch. go on apa clearinghouse and look for pgy-2 spots. i know usc in LA has 2 extra pgy-2 spots. don't cancel your residency until you know for sure u are in somewhere else. also u will need LoRs from your current rez. tell them it is for personal reasons so they will be more understanding. it is a headache for them as well.

 

[DebDynamite]

MB,
If you are in the Southeast, please kindly PM me with the name of your program. I will interviewing this fall and your program sounds a tad too much like my home institution- which has recently swapped one if their inpt facilities for another (larger one) and I fear the interns are getting slammed. Also, we have a female PD, so I'm concerned this is my home institution, which I absolutely loved during my MS3 rotation.

Your situation does not sound supportive or safe at all. I wish you the best in resolving it so that you are comfortable at work again.

 

[DrIng]

It does sound unpleasant and I sympathise. A couple of suggestions:
get a duress button and wear it

Do breakaway training if you are offered it

Always see a patient you don't know with a nurse, ditto for someone you are unsure about

talk to the nurse in charge of the unit and ask their advice, if they know you are feeling unsafe they may well be more sympathetic and offer useful situation specific advice

a related piece of advice, bear in mind that staff safety is everyone's resonsibility. the nursing staff are quite protective of me and will come with me without my suggesting it if they are worried that the patient may be violent. But on the otherhand i attend the duress (which none of the other medical staff on this ward do) and I listen when they say that a patient needs more sedation because it is the nursing staff who will get hit most often. (on a related theme it never hurts to take in the odd packet of chocolate biscuits for the nursing staff)

As for the other doctors patient you just have to tell them that you know they want to talk to a doctor but you aren't their doctor and you need some space to see your patient but you will pass on to their doctor their query- I've never ahd a problem with this approach.

Also look at the ward dynamics, sometimes it is strict adherence to 'the rules' which pisses patients off- and if you look at it you'd be mad being told to turn the TV off in the middle of the movie just ebcause its 10:30pm!

Hope this ramble helps with the safety issues...