Started intern year in Psych and feeling overwhelmed, help

[sprawl2]

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I am scheduled to do Psych ED for my first month of internship. It's my 5th day and I am feeling incompetent half the time.

First of all, it's taking me forever to do a consult and assessment. The attendings usually do one within an hour. I sometimes take more than 2 hours.
It's not because I don't have a good structure during the intreview but because I simply don't know what questions to skip or how to get the pts to speed up. One attending reminded me today that I don't need to ask a lot of the psychosocial or dynamic questions in order to determine the plan from an ED point of view (home, admit, refer, etc)
During my subI, I always had the attending with me holding my hands so that I don't waste time listening to the patients babbling on with irrelevant issues. But when I'm all alone in the ED, I just don't know when to step in and say, "let's not focus on that, let's talk about this". It's not built into me yet.

Furthermore, I always forget to ask questions (the attendings would always ask me about the things I forgot to ask.... how did he tie the rope? how hard did he stab himself? when was this? When was the last time he had a job?)

The notes... oh the notes. One attending always corrects the Mental Status Exam and the Impression portion of my notes. For example, when I feel that the patient has some psychomotor agitation, he would defer otherwise.

One attending notices that I second guess myself too much when I am stressed.
Take today for example, she overheard me telling the nurse about my assessment. When I presented to her, I gave a different (more general, less confident) assessment. She told me straight up that my initial assessment to the nurse was correct.

Bahh!!!!!!
Stressed.

At the end of my MS4, I did a rotation in EM. I was able to complete a patient presentation, assessment and planning in 30min. Now I just feel like I took a trip 2 years backward.....

 

[PistolPete]

Look: regardless of what anyone else is saying around you, everyone is pretty much overwhelmed. Others may be putting up a nice facade, but everyone is still adjusting. Growing pains are real. Yesterday I had short call, only lasted until the early evening, and I left feeling like I got run over by a train, getting paged what felt like every 15 min.

We'll get through it. Chin up!

 

[OldPsychDoc]

I am scheduled to do Psych ED for my first month of internship. It's my 5th day and I am feeling incompetent half the time.
.

👍
Only half the time? You're doing GREAT! 🙂

Welcome to psychiatry. It will get better. Because you will get better at it.
Hang in there.

 

[splik]

If you're finding it easy, something is wrong. This is the next phase in your training - you should feel stretched and challenged, and yes, overwhelmed. it's good you're writing this down. have a look at in a month and you will be surprised how far you will have come in a short time...give it a year and...

absolutely hated my first week of internship - felt like a complete idiot, didn't know where anything was, what services were available, what i was doing, kept getting paged because i kept doing things wrong (e.g. pharmacy calling). week 3 and i am having a great time

can you grab an attending or resident to watch you and give you feedback at some point on your interviewing and assessment that should hopefully give you some pointers on how you might improve. but you will be surprised with practice where you get.

 

[ucsfstudents]

That's internship. Rest assured that the pain comes with the process of learning. Take note of what you learn everyday and try to apply that to the next day. Learn by watching what your attending or senior residents do. Good luck!

 

[Doctor Bagel]

It sounds like you're doing just fine. Internship is stressful, and you're not supposed to be perfect -- actually, you're never supposed to be perfect, but the nice thing about internship is that you have more of a pass. 2 hour evaluations and forgetting questions all happen to the best of us. If you're really worried, maybe ask your attendings for feedback? I'm guessing you're doing much better than you think you're doing.

 

[sunlioness]

I started my (IM) internship in the MICU. I still get kinda queasy thinking about it.

 

[F0nzie]

You'll get faster. I just switched practice settings doing work I already feel comfortable with and it has been taking me 2-4x longer to finish up my evaluations. You're learning AND getting used to a new system. What you're experiencing, IMO, seems completely legitimate.

 

[Bartelby]

Just seconding what others are saying. I happened to start out under a great attending who seemed to intuit exactly how much I could handle and started me out very slow on week one, upped it a little by week two, and had me running at the cap with reasonable confidence by week three. With that outstanding support and mentoring I was able to bypass some of the stress, but still we all have to face the same issues you are facing--- learning the new system, learning how to redirect patients to cut down on interview time, learning tricks for efficiency, learning what parts of the assessment we need to remember to ask every time. Also, seek out and ask questions of your PGY-II and chief resident colleagues, you would be amazed at the tricks and tips they have figured out that can make your life so much easier.

Nothing you mentioned above sounds like a major flaw in you or your abilities. It's just the same stuff we are all dealing with at the start.

 

[sprawl2]

hehe, thanks guys!

Ya, I was worried mostly because I have yet talked to a senior resident yet. They only staff 1 resident at a time at this Psych ED.

Another reason I was getting a little worried is that every other co-intern has done at least 2 rotations at this institution (while 3/10 residents graduated from the home institution, the other 6 each spent 2-3 months doing away rotations here) and I am the only odd ball who hasn't done anything here So I really feel I am running behind whenever I chat with my co-interns.

 

[vistaril]

I am scheduled to do Psych ED for my first month of internship. It's my 5th day and I am feeling incompetent half the time.

First of all, it's taking me forever to do a consult and assessment. The attendings usually do one within an hour. I sometimes take more than 2 hours.
It's not because I don't have a good structure during the intreview but because I simply don't know what questions to skip or how to get the pts to speed up. One attending reminded me today that I don't need to ask a lot of the psychosocial or dynamic questions in order to determine the plan from an ED point of view (home, admit, refer, etc)
During my subI, I always had the attending with me holding my hands so that I don't waste time listening to the patients babbling on with irrelevant issues. But when I'm all alone in the ED, I just don't know when to step in and say, "let's not focus on that, let's talk about this". It's not built into me yet.

Furthermore, I always forget to ask questions (the attendings would always ask me about the things I forgot to ask.... how did he tie the rope? how hard did he stab himself? when was this? When was the last time he had a job?)

The notes... oh the notes. One attending always corrects the Mental Status Exam and the Impression portion of my notes. For example, when I feel that the patient has some psychomotor agitation, he would defer otherwise.

One attending notices that I second guess myself too much when I am stressed.
Take today for example, she overheard me telling the nurse about my assessment. When I presented to her, I gave a different (more general, less confident) assessment. She told me straight up that my initial assessment to the nurse was correct.

Bahh!!!!!!
Stressed.

At the end of my MS4, I did a rotation in EM. I was able to complete a patient presentation, assessment and planning in 30min. Now I just feel like I took a trip 2 years backward.....

it's ED psychiatry....iow, it's the "real world"....not necc of psych, but of life in general(at least the more unfavorable parts)

2 hrs? what are you doing? spending 20 minutes on the interview/assessment/note/plan and then the other 1:40 on bringing the pt takeout and dining with them?

I'm going to give you the most important advice you will ever hear regarding ER psych: it's 99% common sense and 1% psychiatry.

there was a massive thread on the issue of er psych a while back, but as someone who is damn good at er psych, here are the best tips that encapsulate what er psych is about:

1) very few pts actually need to be admitted. Pts do not get better being in an inpt psychiatric hospital in general. they may actually be harmed longterm. Keep that in mind.
2) never write for controlled substances of any kind from pts you are discharging from the er
3) Suicide can be viewed in two ways....one is the acute risk, and one is the chronic risk. A lot of er pts that have psych consults have high chronic risks. Thats not somethign we can do anythign about. The acute risk is what concerns us, and regarding the acute risk it is important to remember that suicide is a moment by moment decision and assessment. What I mean by that it is that it is damn hard to prevent suicides......
4) treat the er docs well. It is their ER. After all, they don't stroll down to your unit and tell you how to run things.
5) You *have* to be comfortable, at least in many pt populations, discharging some pts who flat out tell you "if you discharge me I am going to put a bullet in my head".....or "jump in front of traffic once I leave here"......
6) dont worry about fine points of the mse....completely irrelevant in this setting
7) even though your pts in some psych er's are going to represent the lowest forms of humanity possible, still try to give them the respect they deserve
8) dont admit opiate detox pts. Just because they cant firmly commit to safety does not mean they are suicidal. They are malingering, and you (probably) dont do detox only....

gosh there is more but thats enough for now.