when does residency start?

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Psychotic

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For most places it's the 3rd or last week of June. Expect a few days of general GME orientation for all specialties, then a work-week of orientation to the psych department or so. So, maybe 10 days total. But they'll tell you. My school had a particularly late graduation my year and my program started uncharacteristically early. I wound up graduating on a Friday and having to be at work on Monday. Hahaha. You get blasted with so much at orientation you'll be lucky to remember 10% of it. Most of it doesn't really matter, you'll learn by doing anyways. Just make note of any major rules they tell you (our was "don't park in an unauthorized place. People have been fired for doing that repeatedly after many warnings."
 
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Yes. There is typically a one week, or possibly slightly longer, orientation before July 1.
 
When I think of residency, I'm reminded of this;

Luke: There's something not right here... I feel cold. Death.
Yoda: [points to a cave opening beneath a large tree] That place... is strong with the dark side of the Force. A domain of evil it is. In you must go.
Luke: What's in there?
Yoda: Only what you take with you.
 
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If you need to know for something specific, then it's fine to call program coordinators and ask. I asked at all of my interviews because we were planning our wedding and honeymoon. Everyone was very nice about it.

I had to report the second week of June, FWIW.
 
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If you have done ACLS, sometimes you can shorten orientation a couple of days. If you haven't, ask if taking it now would make a difference. I think most programs start the third or fourth week of June.
 
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Our interns start working July 1, but orientation starts 2 to 2.5 weeks earlier -- we have a really long, stretched out orientation, including specific psychiatry stuff, GME stuff and ACLS. I think part of the goal of having it longer is that we get paid. I suspect if you had anything planned, you could work something out. I remember one of my co-interns missed part of orientation because she had a parent having surgery. So, probably nothing super major to worry about. Most of the residents in other specialties actually start working the week before July 1. So I'd at least hope to be in town for the last two weeks of June.
 
When I think of residency, I'm reminded of this;

Luke: There's something not right here... I feel cold. Death.
Yoda: [points to a cave opening beneath a large tree] That place... is strong with the dark side of the Force. A domain of evil it is. In you must go.
Luke: What's in there?
Yoda: Only what you take with you.

Reminds me of the months of Internal Medicine during my prelim year. Ironically enough, Psychiatry also has to do some months of Internal Medicine as well, which I believe to be utterly useless for that specialty.
 
Reminds me of the months of Internal Medicine during my prelim year. Ironically enough, Psychiatry also has to do some months of Internal Medicine as well, which I believe to be utterly useless for that specialty.
I disagree. There is enough medicine to know and understand when doing psychiatry.
Gone are the days where we have people laying on couches asking, "Und, tell me ov your mother, ja?"
 
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Ironically enough, Psychiatry also has to do some months of Internal Medicine as well, which I believe to be utterly useless for that specialty.
Disagree. Good general medicine knowledge/experience is what separates the good psychiatrists from the dangerous ones…


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You need to be at least somewhat competent at medicine to be a good psychiatrist in this day and age, unless you somehow decide that prescribing lithium, antipsychotics, Depakote, et al. are not important in this field.
 
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I commonly say something along these lines, but in the last two weeks on the inpatient psych unit, I've had two patients who turned out to be just delirious (one from anticholinergics, another from opioids combined with multiple medical comorbidities), a couple whose depression was complicated by poor cognitive function from uncontrolled hyperglycemia, several with significant medical comorbidities that required us to take special precautions with their psychiatric meds, several with significant adverse effects related to their psych meds, a couple with anorexia, one with baseline neutropenia interfering with our ability to prescribe clozapine, etc. Medical training is definitely useful.

But to answer the original question, I started on June 24 last year.
 
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I disagree. There is enough medicine to know and understand when doing psychiatry.
Gone are the days where we have people laying on couches asking, "Und, tell me ov your mother, ja?"
You need to be at least somewhat competent at medicine to be a good psychiatrist in this day and age, unless you somehow decide that prescribing lithium, antipsychotics, Depakote, et al. are not important in this field.

What are the most important things a psychiatrist must know in medicine? I realize everyone likes to say everything, but I'm just trying to prioritze (i.e. OB/GYN knowledge isn't high on the list, nor surgical)...

Neuro
Endocrine
Cardio
Resp
GI
Rheum
Electrolytes
Renal
Hem/Onc
ID
Derm
General ambulatory med
 
I disagree. There is enough medicine to know and understand when doing psychiatry.
Gone are the days where we have people laying on couches asking, "Und, tell me ov your mother, ja?"

That was hilarious!
 
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You need to be at least somewhat competent at medicine to be a good psychiatrist in this day and age, unless you somehow decide that prescribing lithium, antipsychotics, Depakote, et al. are not important in this field.

I don't disagree that these things are important.....the problem is with the idea that one can *only* learn how to manage, monitor,etc these things by doing months of internal medicine(mostly inpatient....outpt might be a little more useful). That's nonsense imo. One doesn't need to spend 4 months on inpatient medicine to know that giving a pt too much cogentin can cause them to have dry mouth, constipation, urinary retention, etc.....we're actually more likely to pick up that stuff on psychiatry services.

Most of the medicine learned on a typical inpatient medicine month is much less useful than the medical stuff that is related to psychiatry we learn.....on inpatient psychiatry.

Agree with the derm guy.
 
I had a patient recently who had a history of psychosis and ended up getting admitted to psych because of a decompensation of the psychosis. She also had a lot of other problems that made it hard for her to communicate her symptoms - I won't go into detail due to risk of revealing her identity. The ED did everything correctly and she ended up getting admitted to psych. She subsequently spiked a fever, and on further workup, she turned out to have severe bacterial meningitis. Her nuchal rigidity was very mild, and even the neurologists weren't able to pick it up conclusively. Head CT was normal. Luckily, the psych resident on call was clever enough to do a thorough medical workup and start appropriate antibiotic therapy while we were waiting for the results of the workup. If it hadn't been for our IM/neuro training, she probably would have died.
 
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I had a patient recently who had a history of psychosis and ended up getting admitted to psych because of a decompensation of the psychosis. She also had a lot of other problems that made it hard for her to communicate her symptoms - I won't go into detail due to risk of revealing her identity. The ED did everything correctly and she ended up getting admitted to psych. She subsequently spiked a fever, and on further workup, she turned out to have severe bacterial meningitis. Her nuchal rigidity was very mild, and even the neurologists weren't able to pick it up conclusively. Head CT was normal. Luckily, the psych resident on call was clever enough to do a thorough medical workup and start appropriate antibiotic therapy while we were waiting for the results of the workup. If it hadn't been for our IM/neuro training, she probably would have died.

this story doesn't completely add up though- like what 'thorough' medical workup did the psych intern/resident do without medicines input? She certainly didn't order or do the LP herself. It's unlikely she started IV abx before consulting medicine/neuro. what exactly was the order and progression of the workup once the pt spiked a fever on psych?

Additionally, let's keep in mind that we did go to medical school. We should know how to do some very basic things(like the initial steps in workup when someone spikes a fever) without spending 4 months on inpatient IM. Heck most every ms3 can do that at the level we need to be able to do on inpatient psych.

Also, for psych interns and residents who are used to doing things like tinkering with someones bp meds or metform dose on inpatient psych, community/pp inpatient world is a completely different animal. You're not expected to manage htn, dm, hld, etc..at ANY level.......if it's completely stable you would just resume their meds in a training program perhaps, but in most community psych units you wouldn't. You will almost certainly have a hospitalist group who consults on these patients to increase revenue. You wouldn't be allowed to say "well due to my excellent pgy1 medicine training I feel good about restarting this pt's metform at the current dose, so no assistance is needed"....

Even at some academic medical centers, I've heard that a push is about to begin for the hospitalist group to start doing way more admission consults for such mundane basic med mgt issues. These hospital systems have a budget and cost structure too, and right now some $ are being lost whenever the psych team starts a pts home 'medical' meds rather than putting in a medicine consult. What they would do is send it to the non-teaching medicine consult service, and if there isn't one start one up(staffed by mostly nps/pas) to do this.
 
I had a patient recently who had a history of psychosis and ended up getting admitted to psych because of a decompensation of the psychosis. She also had a lot of other problems that made it hard for her to communicate her symptoms - I won't go into detail due to risk of revealing her identity. The ED did everything correctly and she ended up getting admitted to psych. She subsequently spiked a fever, and on further workup, she turned out to have severe bacterial meningitis. Her nuchal rigidity was very mild, and even the neurologists weren't able to pick it up conclusively. Head CT was normal. Luckily, the psych resident on call was clever enough to do a thorough medical workup and start appropriate antibiotic therapy while we were waiting for the results of the workup. If it hadn't been for our IM/neuro training, she probably would have died.

I'm hoping she did that with the assistance of the medicine and neurology services. While we might have a really strong background in IM and neurology, we don't have the same expertise as infectious disease and neurology services in dealing with something like meningitis. Based on that, you owe it to your patient to consult those other services for a critically ill patient.

Not to say your fellow intern isn't great and didn't do an appropriate job, and if she had less training, she might not have known to be concerned and ask for help. However, I get worried about providers being cowboys.
 
I'm hoping she did that with the assistance of the medicine and neurology services. While we might have a really strong background in IM and neurology, we don't have the same expertise as infectious disease and neurology services in dealing with something like meningitis.

thats why I said the story didn't make sense.....there is no way a psych intern/resident anywhere starts treatment(IV abx) for a presumptive dx of bacterial meningitis before consulting medicine. It takes all of a minute to page someone/pick up the phone and say "hey I've got this girl here on the psych unit who suddenly started circling the drain, looks like crap, she's got a fever and neck stiffness. What do you guys want me to do?". In all likelihood someone from medicine(or one of the rapid response teams which are staffed by mediciney people) is going to come down and assess the patient, and then if needed facilitate transfer and do their own workup(probably LP and a bunch of labs) and they would of course be the ones deciding to start IV abx(and pick which one) for a presumed bacterial meningitis infection.

the only thing the psych intern/resident needs to do in a situation like this is just be aware that fever and meningeal signs are...ummm....not good and warrant immediate action from the medicine people. one doesn't need to do 4 months of IM(after med school) to know that.
 
I'm hoping she did that with the assistance of the medicine and neurology services. While we might have a really strong background in IM and neurology, we don't have the same expertise as infectious disease and neurology services in dealing with something like meningitis. Based on that, you owe it to your patient to consult those other services for a critically ill patient.

Not to say your fellow intern isn't great and didn't do an appropriate job, and if she had less training, she might not have known to be concerned and ask for help. However, I get worried about providers being cowboys.

Yes, psych should consult for bacterial meningitis!
 
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Also, for psych interns and residents who are used to doing things like tinkering with someones bp meds or metform dose on inpatient psych, community/pp inpatient world is a completely different animal. You're not expected to manage htn, dm, hld, etc..at ANY level.......if it's completely stable you would just resume their meds in a training program perhaps, but in most community psych units you wouldn't. You will almost certainly have a hospitalist group who consults on these patients to increase revenue. You wouldn't be allowed to say "well due to my excellent pgy1 medicine training I feel good about restarting this pt's metform at the current dose, so no assistance is needed"....
.

In the community psych programs I have seen, the psych certainly has the option of consulting medicine, but I disagree that consulting medicine is mandatory (at least in my part of the country). And if the psych ward is not physically connected to the main hospital (is across the street, etc); the psychiatrist better be prepared to do some basic medicine, especially on weekends.
 
Yes, of course he consulted neuro. But it wasn't an obvious consult... the patient wasn't able to communicate her symptoms, so he had to have a pretty good understanding of bacterial meningitis in order to suspect it. She didn't have neck stiffness or leukocytosis and wasn't able to communicate her headache. And she really didn't look that sick. But he thought that she might have some meningismus on physical exam, she had some risk factors, and she was spiking a fever. You don't consult neuro every time a patient spikes a fever, and most psychiatrists don't check for meningismus when admitting a patient, even if they do have a fever. Even the neuro team had a low suspicion for meningitis until the LP results came back. It wasn't a classic textbook picture of "fever, headache, neck stiffness."

Anyway, the whole story is complicated, and this is mostly a digression. The point is that the medical training is useful. We can spend forever debating the extent of its utility.
 
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Yes, of course he consulted neuro. But it wasn't an obvious consult... the patient wasn't able to communicate her symptoms, so he had to have a pretty good understanding of bacterial meningitis in order to suspect it. She didn't have neck stiffness or leukocytosis and wasn't able to communicate her headache. And she really didn't look that sick. But he thought that she might have some meningismus on physical exam, she had some risk factors, and she was spiking a fever. You don't consult neuro every time a patient spikes a fever, and most psychiatrists don't check for meningismus when admitting a patient, even if they do have a fever. Even the neuro team had a low suspicion for meningitis until the LP results came back. It wasn't a classic textbook picture of "fever, headache, neck stiffness."

Anyway, the whole story is complicated, and this is mostly a digression. The point is that the medical training is useful. We can spend forever debating the extent of its utility.

Spiking a fever for unexplained reasons sounds like a good time to consult the medicine service. Good for your colleague, though, for suspecting the right diagnosis and consulting neuro as well.

Anyway, about medical training -- we don't refresh those skills with ongoing training in IM and neurology, so they get dated and atrophied regardless of how much we try to keep up. The medicine folks and the neurology are almost always going to be able to do it better than us, so I think having a low barrier to consult honestly makes sense, especially with an acutely ill patient. I agree that we should be comfortable with things like treating hypertension and basic diabetes management. We also need to be able to know when to consult -- perhaps that's the real benefit of those IM and neuro months.
 
Yeah, that was the example I mentioned because it happened the day I posted it. I use medical training every day.
 
Spiking a fever for unexplained reasons sounds like a good time to consult the medicine service. Good for your colleague, though, for suspecting the right diagnosis and consulting neuro as well.

Anyway, about medical training -- we don't refresh those skills with ongoing training in IM and neurology, so they get dated and atrophied regardless of how much we try to keep up. The medicine folks and the neurology are almost always going to be able to do it better than us, so I think having a low barrier to consult honestly makes sense, especially with an acutely ill patient. I agree that we should be comfortable with things like treating hypertension and basic diabetes management. We also need to be able to know when to consult -- perhaps that's the real benefit of those IM and neuro months.

if someone needs 4 months of IM to know that they need to consult medicine immediately for a pt with a fever an meningeal signs, I'd argue that person is pretty hopeless to begin with though.
 
When's the last time you checked a patient for meningismus? The point is to be able to detect the meningeal signs. I don't think even a medicine consult would have picked that up... it was neurologist-level stuff. Also, a medicine doc probably wouldn't have realized that the patient's AMS was atypical for a chronic psychosis. That's why the patient ended up getting admitted to psychiatry instead of neurology.

But again, this is a digression. There have been a thousand debates about the necessity of medical training in psych. Personally, I think that I use it a fair bit. The most recent example (yesterday) was when I had a patient admitted who had a BP of 120/90 and was on a large antihypertensive regimen and we suspected noncompliance, and he was too demented to clarify things on his own... if I didn't know about hydralazine dosing, I could have started him on his home meds and he would have gotten dangerously hypotensive. But I'd used enough hydralazine on the medicine service to know that a person if a person has a BP of 120 despite not getting his hydral for several hours in the ED, he clearly doesn't need the amount of hydral that he was taking. It seems silly to call a medicine consult to ask whether to start a patient on his home meds, and if I hadn't done a medicine rotation, I probably would have just started home meds with the assumption that his dosing was appropriate. I run into similar situations with insulin all the time... i.e. the thought that "this patient is on a LOT of insulin, and I don't have any particular reason to suspect noncompliance, but I just find it hard to believe that they need this much... I'm guessing that the NP at their outpatient free clinic is just uptitrating the insulin because of a high A1c, and it's not working because the A1c is still high, so the insulin gets uptitrated again (which happens ALL THE TIME, especially in patients whose psych illness limits their ability to provide a reliable history to their outpatient IM doc). I'd better put them on a sliding scale and recalculate their actual insulin requirement from scratch, and then I'll call a diabetes consult in the morning just to be safe." I learned that on my intern year IM rotation, not in med school.

Many of those situations could be replaced by calling a medical consult on any patient with chronic medical illnesses, but I think that'd be an unnecessary burden on the medical service. It makes more sense for the psychiatrist to have that basic level of training, especially since patients with serious psychiatric illnesses often have such poor management of their general medical problems. I'll call a medicine consult if first-line management isn't working. Akin to a PCP starting 20mg of celexa for depression, and referring to a psychiatrist if that doesn't work.
 
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When's the last time you checked a patient for meningismus? The point is to be able to detect the meningeal signs. I don't think even a medicine consult would have picked that up... it was neurologist-level stuff. Also, a medicine doc probably wouldn't have realized that the patient's AMS was atypical for a chronic psychosis. That's why the patient ended up getting admitted to psychiatry instead of neurology.

But again, this is a digression. There have been a thousand debates about the necessity of medical training in psych. Personally, I think that I use it a fair bit. The most recent example (yesterday) was when I had a patient admitted who had a BP of 120/90 and was on a large antihypertensive regimen and we suspected noncompliance, and he was too demented to clarify things on his own... if I didn't know about hydralazine dosing, I could have started him on his home meds and he would have gotten dangerously hypotensive. But I'd used enough hydralazine on the medicine service to know that a person if a person has a BP of 120 despite not getting his hydral for several hours in the ED, he clearly doesn't need the amount of hydral that he was taking. It seems silly to call a medicine consult to ask whether to start a patient on his home meds, and if I hadn't done a medicine rotation, I probably would have just started home meds with the assumption that his dosing was appropriate. I run into similar situations with insulin all the time... i.e. the thought that "this patient is on a LOT of insulin, and I don't have any particular reason to suspect noncompliance, but I just find it hard to believe that they need this much... I'm guessing that the NP at their outpatient free clinic is just uptitrating the insulin because of a high A1c, and it's not working because the A1c is still high, so the insulin gets uptitrated again (which happens ALL THE TIME, especially in patients whose psych illness limits their ability to provide a reliable history to their outpatient IM doc). I'd better put them on a sliding scale and recalculate their actual insulin requirement from scratch, and then I'll call a diabetes consult in the morning just to be safe." I learned that on my intern year IM rotation, not in med school.

Many of those situations could be replaced by calling a medical consult on any patient with chronic medical illnesses, but I think that'd be an unnecessary burden on the medical service.

people tend to like work(especially quick, easy, routine work) though, because it's that work that pays our student loans, makes our mortgage payment, our car insurance, etc....now iirc you're at a very large teaching hospital, so what you are encountering now doesn't represent the real world. The fact you use language like 'unnecessary burden on the medical service' tells me this. In the real world a hospitalist group jumps at the chance for such work.

Even if you spend your whole career in a large academic medical center, you're not going to be a 50 year old attending who is pontificating on a pt's blood pressure or insulin. Like I said in another post my sense is that we're seeing a shift towards focusing more on the bottom line and maximizing profitable revenue streams in clinical academia. In talking to attendings I know this is true at my institution, and I wonder if you ask yours whether they would say the same thing. If it hasn't come yet I would expect it to- that's the nature of what medicine is becoming.

As for your question about meningeal signs, I don't think I've ever physically checked a pt for such things. Like kernigs or bruudzinski or whatever they are called. Maybe I have but I dont remember. What I meant was that basic common sense medical training would tell me that a pt complaining of photophobia, neck stiffness, etc has meningeal signs. And I may be using the terms signs and symptoms wrong, but you get what I'm saying.

Another aspect of medical training in something like IM I've seen is that the learning curve seems to be such that towards the end of pgy1 year/start of pgy2 the medicine residents really seem to 'get it' and enter a whole different level of competence. I remember being on an inpatient medicine month with two categorical medicine people in October or so and thinking "hey, I don't know quite as much as them here but the difference isn't too massive, and the pgy3 resident is providing a lot of supervision for all of us". Then I ran into them in June or July and they were on a whole different level....it wasn't a linear thing. Somewhere along their medicine training(much past what we get....maybe it's the ICU stuff), everything for decent medicine residents clicks. It's safe to say they probably went from knowing 15% more than me in October to 200% more than me in July.
 
When's the last time you checked a patient for meningismus? The point is to be able to detect the meningeal signs. I don't think even a medicine consult would have picked that up... it was neurologist-level stuff. Also, a medicine doc probably wouldn't have realized that the patient's AMS was atypical for a chronic psychosis. That's why the patient ended up getting admitted to psychiatry instead of neurology.

But again, this is a digression. There have been a thousand debates about the necessity of medical training in psych. Personally, I think that I use it a fair bit. The most recent example (yesterday) was when I had a patient admitted who had a BP of 120/90 and was on a large antihypertensive regimen and we suspected noncompliance, and he was too demented to clarify things on his own... if I didn't know about hydralazine dosing, I could have started him on his home meds and he would have gotten dangerously hypotensive. But I'd used enough hydralazine on the medicine service to know that a person if a person has a BP of 120 despite not getting his hydral for several hours in the ED, he clearly doesn't need the amount of hydral that he was taking. It seems silly to call a medicine consult to ask whether to start a patient on his home meds, and if I hadn't done a medicine rotation, I probably would have just started home meds with the assumption that his dosing was appropriate. I run into similar situations with insulin all the time... i.e. the thought that "this patient is on a LOT of insulin, and I don't have any particular reason to suspect noncompliance, but I just find it hard to believe that they need this much... I'm guessing that the NP at their outpatient free clinic is just uptitrating the insulin because of a high A1c, and it's not working because the A1c is still high, so the insulin gets uptitrated again (which happens ALL THE TIME, especially in patients whose psych illness limits their ability to provide a reliable history to their outpatient IM doc). I'd better put them on a sliding scale and recalculate their actual insulin requirement from scratch, and then I'll call a diabetes consult in the morning just to be safe." I learned that on my intern year IM rotation, not in med school.

Many of those situations could be replaced by calling a medical consult on any patient with chronic medical illnesses, but I think that'd be an unnecessary burden on the medical service. It makes more sense for the psychiatrist to have that basic level of training, especially since patients with serious psychiatric illnesses often have such poor management of their general medical problems. I'll call a medicine consult if first-line management isn't working. Akin to a PCP starting 20mg of celexa for depression, and referring to a psychiatrist if that doesn't work.

There are two different things going on here. Should psychiatrist know basic medicine? Sure. Will they use basic medicine skills? Sure.

Should psychiatry make life/death decisions on things outside of their area of expertise (Internal Medicine)? No.

Having basic internal medicine skills is a good thing. Playing internal medicine doc in critical patients is a bad thing.

So the debate will continue because both sides are using the word "medicine" and applying them to drastically different patient populations.
 
There are two different things going on here. Should psychiatrist know basic medicine? Sure. Will they use basic medicine skills? Sure..

see in many settings I don't completely agree with the latter. It really depends on what you mean by 'basic medicine skills'. I don't consider things like knowing what physical side effects tricyclics cause 'basic medicine skills'. Or knowing to look for orthostasis when starting some antipsychotics 'basic medicine skills'. Or knowing how to monitor and consider certain organ systems when using lithium 'basic medicine skills'. Obviously a lot of psychiatrists are going to need to known these things.

When I think of basic medical skills, I think of things like evaluating and and managing hyperglycemia, hypertension, COPD, dysuria. And in interviewing for many(> 5) different inpatient based community hospital jobs, it was made very clear that the psychiatrists staffing the unit would not be expected or allowed to handle such matters.
 
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