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- May 31, 2018
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Hey there SDN. I posted a very similar... Essay, I suppose, on another forum, but as I try to formulate my thoughts, thinking about my place in the world, I thought it would be appropriate to ask here as well.
This is a long post, so I really do apologise, but if you have the time and will indulge me, I would love to hear your perspective.
I am a third year osteopathic medical student who hopes to focus his work in the realm of mental/social health – “narrative medicine” as I like to say. However, I am at a cross-roads at my current point, reflecting back on the experiences I have had thus far during my rotations. To this end, I am asking myself if my path is better served through the world of Psychiatry or the world of Family Medicine – to be a psychologically minded physician. I am hoping students, residents, and even attendings read this and reply.
Before medicine, I worked for two years in residential homes for youth with behavioural needs (ODD, Autsim-Asperger’s spectrum), as well as working in a drop-in centre for at-risk youth in our small town (youth that were homeless, from abusive homes, living couch to couch, engaging in substances, and quite a number of teen pregnancies). It was work I found deeply meaningful, and the role of “narrative medicine”, their psycho-social story, pushed me to want to work in this area professionally.
I came into medical school with the eye of Psychiatry, admittedly because I was originally on a Clinical Psychology train – but thought that with the ability to do both medications and therapy, the integration of both is stronger than the two fragmented. Admittedly, I had a very specific vision of what Psychiatry is, and it was through a psycho-therapeutic lens.
Thinking back to my rotations, my Psychiatry rotation (which was in a training program) was biologically minded. It was a month that tried to give me the breadth of Psychiatry – but by trying to do so much, it fell short. Most of my outpatient week was spent sitting in the conference room studying. Any time I got to sit in during an encounter, it was a medicine management visit. Inpatient was the most robust, and I was able to do intake on mainly addiction patients. However, the two to three day stabilise and send them to outpatient was something I did not resonate well with – I wanted to know the patient’s deeper, their narratives, but that was the job for outpatient. I had trans patient who I connected well with, she came in for substance abuse stabilisation following a “straw that broke the camel’s back” situation with her boyfriend, telling me her story of abuse and searching for her place in the world. But, for the in-patient team, we were here to stabilise, not get into the “weeds”.
These “narrative medicine” moments I think back to my time in the youth center I did encounter on my FM rotations. I remember I spent a month with a county health director in a rural area of the state. He had, what was labelled as, a “HTN f/u” visit. It was all but that. A mother who was in an emotionally abusive relationship, and the previous visits with this doc were all about psyching herself up to leave her husband and move in with her sons who also wanted her safe with them. Coincidentally, my preceptor sent me to spend a day with the a LCSW in the county health-system. I saw that patient again for a therapy appointment with them. It is these interactions that give me meaning. I saw similar moments of humanity when spent a month with an FM training program – a gay patient who is on insulin, but has not been taking it properly for a little while due to life stressors with dynamics between his family and his boyfriend; a youth patient from a low-socioeconomic environment whose entire visit was sexual education counselling; a young pregnant mother engaged in SUD.
It is the humanity of the patient that makes me what to focus on the work I wish to – addictions, psycho-social health. I want to be integrative.
People like to mention that “FM has a lot of Psych!”, yet they refer to the ability to start a medication. It is not the authority to prescribe an SSRI and follow STAR-D that pulls me into this work – it’s the integration of this person’s entire story. How is that medication relating to their psycho-socio-cultural context? Just as insulin isn’t going to “fix” a diabetic patient without them changing their lifestyle, an SSRI won’t “fix” depression unless we also address the context outside the clinic room. Yet, as many psychotherapy psychiatrists have spoken about and worry on, the modern training in Psychiatry is moving towards that medication management of the severe and acute, with therapy and psycho-social medicine being referred to the psychologist. This is actually something a mentor of mine said will frustrate me in Psychiatry training (she wants me in her camp of FM). Yet, it is Psych that offers the potential for that therapeutic skill-set? Unlike the UK or Canada, we don't encourage FM to learn therapy.
In terms of residents... I found myself meshing very well with FM residents, IM residents, and even my Surg residents (my surgery lead gave me a hug on my last day wishing me good luck on my future). I "vibed", for a lack of a better term. But when on Psych, I felt such a wall between me and the resident...
I suppose I am self doubting and wondering. I only had one month of Psychiatry, but two months of FM. With the virus crisis we are currently in, I am not sure if my outpatient Child and Adolescent rotation will still happen in July. I have a dream, that one say I, as a physician, can work and “staff” at a youth centre like the one I worked it. Drop-in counselling for these misunderstood kids. Sexual health, substance health, mental health screenings for those that don’t have doctor’s, or rather have had a difficult time finding that non judgemental person that they can trust.
I ask myself, if I was an attending physician tomorrow, and my patients were these kids – in what way would I best serve them? Advocate for them?
If you read this, I really do apperciate.
Thank you.
This is a long post, so I really do apologise, but if you have the time and will indulge me, I would love to hear your perspective.
I am a third year osteopathic medical student who hopes to focus his work in the realm of mental/social health – “narrative medicine” as I like to say. However, I am at a cross-roads at my current point, reflecting back on the experiences I have had thus far during my rotations. To this end, I am asking myself if my path is better served through the world of Psychiatry or the world of Family Medicine – to be a psychologically minded physician. I am hoping students, residents, and even attendings read this and reply.
Before medicine, I worked for two years in residential homes for youth with behavioural needs (ODD, Autsim-Asperger’s spectrum), as well as working in a drop-in centre for at-risk youth in our small town (youth that were homeless, from abusive homes, living couch to couch, engaging in substances, and quite a number of teen pregnancies). It was work I found deeply meaningful, and the role of “narrative medicine”, their psycho-social story, pushed me to want to work in this area professionally.
I came into medical school with the eye of Psychiatry, admittedly because I was originally on a Clinical Psychology train – but thought that with the ability to do both medications and therapy, the integration of both is stronger than the two fragmented. Admittedly, I had a very specific vision of what Psychiatry is, and it was through a psycho-therapeutic lens.
Thinking back to my rotations, my Psychiatry rotation (which was in a training program) was biologically minded. It was a month that tried to give me the breadth of Psychiatry – but by trying to do so much, it fell short. Most of my outpatient week was spent sitting in the conference room studying. Any time I got to sit in during an encounter, it was a medicine management visit. Inpatient was the most robust, and I was able to do intake on mainly addiction patients. However, the two to three day stabilise and send them to outpatient was something I did not resonate well with – I wanted to know the patient’s deeper, their narratives, but that was the job for outpatient. I had trans patient who I connected well with, she came in for substance abuse stabilisation following a “straw that broke the camel’s back” situation with her boyfriend, telling me her story of abuse and searching for her place in the world. But, for the in-patient team, we were here to stabilise, not get into the “weeds”.
These “narrative medicine” moments I think back to my time in the youth center I did encounter on my FM rotations. I remember I spent a month with a county health director in a rural area of the state. He had, what was labelled as, a “HTN f/u” visit. It was all but that. A mother who was in an emotionally abusive relationship, and the previous visits with this doc were all about psyching herself up to leave her husband and move in with her sons who also wanted her safe with them. Coincidentally, my preceptor sent me to spend a day with the a LCSW in the county health-system. I saw that patient again for a therapy appointment with them. It is these interactions that give me meaning. I saw similar moments of humanity when spent a month with an FM training program – a gay patient who is on insulin, but has not been taking it properly for a little while due to life stressors with dynamics between his family and his boyfriend; a youth patient from a low-socioeconomic environment whose entire visit was sexual education counselling; a young pregnant mother engaged in SUD.
It is the humanity of the patient that makes me what to focus on the work I wish to – addictions, psycho-social health. I want to be integrative.
People like to mention that “FM has a lot of Psych!”, yet they refer to the ability to start a medication. It is not the authority to prescribe an SSRI and follow STAR-D that pulls me into this work – it’s the integration of this person’s entire story. How is that medication relating to their psycho-socio-cultural context? Just as insulin isn’t going to “fix” a diabetic patient without them changing their lifestyle, an SSRI won’t “fix” depression unless we also address the context outside the clinic room. Yet, as many psychotherapy psychiatrists have spoken about and worry on, the modern training in Psychiatry is moving towards that medication management of the severe and acute, with therapy and psycho-social medicine being referred to the psychologist. This is actually something a mentor of mine said will frustrate me in Psychiatry training (she wants me in her camp of FM). Yet, it is Psych that offers the potential for that therapeutic skill-set? Unlike the UK or Canada, we don't encourage FM to learn therapy.
In terms of residents... I found myself meshing very well with FM residents, IM residents, and even my Surg residents (my surgery lead gave me a hug on my last day wishing me good luck on my future). I "vibed", for a lack of a better term. But when on Psych, I felt such a wall between me and the resident...
I suppose I am self doubting and wondering. I only had one month of Psychiatry, but two months of FM. With the virus crisis we are currently in, I am not sure if my outpatient Child and Adolescent rotation will still happen in July. I have a dream, that one say I, as a physician, can work and “staff” at a youth centre like the one I worked it. Drop-in counselling for these misunderstood kids. Sexual health, substance health, mental health screenings for those that don’t have doctor’s, or rather have had a difficult time finding that non judgemental person that they can trust.
I ask myself, if I was an attending physician tomorrow, and my patients were these kids – in what way would I best serve them? Advocate for them?
If you read this, I really do apperciate.
Thank you.
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