What is the appropriate amount of inpatient psychiatry?

[Chrismander]

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I guess this is a little late, since the ACGME change to inpatient psych requirements (from 9 months to 6 months) happened awhile ago. But I happened to see a post about this topic in a psych blog that got me thinking about the issue, and was curious what consensus, if any, was out there.

I can see some pros and cons to decreasing a program's inpatient psych requirements to 6 months. Additional specialty exposure, more time for research, more time on C/L, or add in a few more months of non-psych (maybe 2 months of endo, the way we do neuro--god knows we'll be dealing with almost as many endo issues in our patients as neuro). Or maybe just more flexibility, to create "tracks" for different residents (research/academic/etc).

But maybe 6 months is just way too short. My perspective is pretty limited since I've only done inpatient, ER, and C/L, and I have no sense on how long it would take to get comfortable with any of those let alone the other areas like addictions, outpatient, etc. From my limited perspective, C/L seemed like it would take more time than inpatient to get good at.

What do you guys think? One argument I read seemed to intimate that psychiatry would be taken less seriously as a specialty, because we were getting rid of our "harder" rotations, and other specialties emphasize inpatient training (the latter seems like a pretty poor argument IMHO). What's your opinion on the "hardness" of psych inpatient? It didn't seem more "grueling" than ER or C/L to me, but maybe my inpatient experience was more chill than the average?

 

[OldPsychDoc]

I think it's too short. Especially with most programs "front-loading" inpatient in your first year of two of residency, I think it weakens your experience in dealing with more acutely ill patient--evaluating, formulating, initiating treatment. There's also the "learning curve" issue. I think even after 9 months when it's done by the end of PGY2, you still feel really "green" (not in the good environmentally-conscious sense). I could see having 6 months in PG1 & 2, then a couple of months of senior resident inpatient time though. There's just a different level of understanding and knowing what to do by that time--kind of an "Ah ha! I really have learned something in the past 3 years!"

Admittedly, I'm an inpatient attending, and far more psychiatric work-hours are spent in non-inpatient settings, but I think it's a really important part of training that helps us better understand the "real pathology" in a way that one wouldn't just training in a more outpatient-weighted system.

(Geez--just 4 years out of training, and my personality is already becoming more like my user name. This and the whole elimination of oral boards. "You kids these days have it way too soft... Why, back in my day..."🙄)

 

[Faebinder]

I havent been through the process yet, but I sense a push towards diversifying the experience with more electives and I feel this is a positive thing. Focusing mostly on inpatient is a loss for psychiatry and we now have so much more distinct subspecialties to do: Forensic, sleep, child, adminstrative, addiction. The field can't continue to improve if we limit ourselves.

Sides, it's a four year residency, at a certain point handling psych patients will click in.

 

[whopper]

Inpatient psychiatry IMHO is the nuts & bolts of psychiatric training. I think any program should have a good foundation of this. 6 months IMHO is too short, however I also think doing it for too many months straight can be taxing (at least in the hospital I'm in) on a resident since it is one of the tougher rotations.

I do though think that inpatient suffers from these aspects in terms of training a resident.
-lack of being able to sit down with a patient & give them a psychotherapy session lasting an hour. When a resident is covering several patients, resident could of course do this, if they want to go home 7pm everday. On a short term care facility, the patient is only going to be there for a few days, so psychotherapy doesn't really have a chance to foment, unless you're looking for superficial, supportive psychotherapy.
-on short term care facilities-lack of ability to see the continuity of care once the patient is discharged. I hadn't seen that until my 3rd year. For the first 2 years I felt like we were discharging too early. When I saw the available programs my 3rd year, I didn't think the discharges were too early anymore because I saw where they were going to and what was being done in outpatient.

I don't think 1 magic number of months can be applied to all programs. My program is divided into 2 different hospital systems. 1 in Camden, one in Atlantic County NJ. The Camden program only has a voluntary unit that carries about 12 patients total with more than 1 resident covering that unit--each one only carries about 4 patients. The Atlantic County hospital has a 28 bed involuntary & voluntary. A resident there typically carries 10 or more patients at any time. Needless to say I think the Atlantic County inpatient is much more intense.

 

[Chrismander]

I think it's too short. Especially with most programs "front-loading" inpatient in your first year of two of residency, I think it weakens your experience in dealing with more acutely ill patient--evaluating, formulating, initiating treatment. There's also the "learning curve" issue. I think even after 9 months when it's done by the end of PGY2, you still feel really "green" (not in the good environmentally-conscious sense). I could see having 6 months in PG1 & 2, then a couple of months of senior resident inpatient time though. There's just a different level of understanding and knowing what to do by that time--kind of an "Ah ha! I really have learned something in the past 3 years!"

Your comments about "front-loading" are interesting, OPD, esp. in light of the interview I read tonight that started this. I'm glad you said that about splitting the inpatient, esp. since you're an inpatient guy. The program I'll be starting at in July does 6 months inpt in PGY-1, all outpatient PGY-2, and 3 months inpt PGY-3. This was a big selling point when I was applying, because of the idea of seeing "longitudinal" outpatient care, and from an early point in the residency. However, I wasn't sure if splitting the inpatient would adversely affect inpatient education--thanks for the reassurance.

This interview with Dr. Lim (interview link below, her commentary in support of the 9 month requirement is linked in the interview) spooked me earlier tonight. I misread it (aka skimmed quickly and didn't read her cited sources**) and thought it said that residents from programs with outpatient PGY-2's are

"more likely to underestimate the severity of patient symptoms and to misinterpret symptoms of Axis I disorders as Axis II psychopathology. Those residents also were more hesitant to prescribe psychotropic drugs, had difficulty making rapid decisions and interventions, and had greater difficulty developing a professional identity"

So naturally I freaked out and thought I'd be emerging from my program in four years with a weak professional identity, sluggish thought process, and hesitancy to prescribe drugs to Axis II folks (though the latter may actually be a perk...)

http://www.clinicalpsychiatrynews.com/article/PIIS0270664407706884/fulltext

**Regarding the 1991 study they mention: The program described (Connecticut) was once a PGY2-4 program. It originally did a Medicine/Traditional PGY-1, then all outpatient PGY2, all inpatient PGY3, and some other stuff in PGY4. Sometime in the mid to late 1980's they switched the PGY2 and 3 years (so inpatient was first), and found that residents seemed to do better on the inpatient wards when they did them before outpatient. Lim mentioned this just to emphasize the importance of early exposure to inpatient, though she's candid about the lack of research demonstrating any "magic number" for number of months, nor does she claim that this study shows that putting some inpatient months in the PGY-3 makes you ******ed (much to my relief. gotta read these things fully before I open my damn mouth).

 

[Faebinder]

Just finished my first week of inpatient. Maaaan... was hoping for a little more variety. We have a local 3.7 days admission limit on the involuntary service so patients don't stay long. The problem is that many are the "I stopped taking medications after I was discharged" types.

Will there be a real difference between 6 months and 9 months? We'll see as this goes on.... I daresay the pre-residency fellowship helped a lot in handling many of the daily management details. I can sense I'm still in the "I don't know that I don't know what I don't know" stage (aka DK-Cube) Must proceed with caution and refrain from becoming paranoid... like the patients! 😏

 

[Anasazi23]

I 100% agree with Dr. Lim's assertion that PGY-II is too soon to see outpatients. I'm surprised that this is even allowed.

In my opinion, PGY-IIs are way too green to use that year (the pivotal outpatient year again in my opinion), to experiment with meds, take safe chances that build their internal database of drug profiles, and make meaningful pharmacological treatment changes.

I personally did over 1 year of inpatient. I feel as though I still have a tremendous amount to learn. I'm reasonably competent with most typicals, but I need more time to get fully comfortable with all of them. Same goes for more rare disorders, etc.

 

[whopper]

The problem is that many are the "I stopped taking medications after I was discharged" types.

Being that I worked at the same place, the place does present with several interesting patients. Just that a lot of them do fit the above category.