Which psychiatric subspeciality do you find most fulfilling and why?

[nonick123]

I am not located in the US, but working in a psych ED. I am still a medical student having some concerns. I see the same patients come back again and again in the ED after a few months after hospitalization. I just feel we are not really helping them and making a difference in their lives and that, honestly said, demotivates me a bit. Is that common in private practice or the other subspecialities like addiction, child, etc ?

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[Mass Effect]

Mental illness is chronic, every bit as so as COPD or MS. You will have patients relapse in every subspecialty of this field. It's the nature of chronic illnesses. After residency, you can handpick patients and choose how sick your patient population is if you do outpatient, but even they will relapse every once in a while.

 

[TexasPhysician]

I am not located in the US, but working in a psych ED. I am still a medical student having some concerns. I see the same patients come back again and again in the ED after a few months after hospitalization. I just feel we are not really helping them and making a difference in their lives and that, honestly said, demotivates me a bit. Is that common in private practice or the other subspecialities like addiction, child, etc ?

You are working in an ED which is probably the setting that is the most discouraging in Psych. You do very minimal in the ED for long-term stabilization.

I have many patients either become stable on meds or go into remission and taper off of them.

 

[Monocles]

Child 100%!

Typically I find younger population to be more optimistic, motivated, resilient. There just seems to be a "willingness" to get well. Less (entrenched) personality disorders, malingering, etc. In my short 1.5 months into fellowship no one has threatened to shoot me for benzos yet! Parents could be a handful at times but ultimately a vast majority of them care for their kiddos and just want to help them out.

Personally I just really love working with that population!!!

 

[NickNaylor]

I am not located in the US, but working in a psych ED. I am still a medical student having some concerns. I see the same patients come back again and again in the ED after a few months after hospitalization. I just feel we are not really helping them and making a difference in their lives and that, honestly said, demotivates me a bit.

Sounds about right. I do a lot of ED work, and it can be demoralizing. As noted above, though, I would not consider ED work as representative of most of psychiatry. Get some exposure elsewhere - you will be more likely to see people get better in a setting like an outpatient practice. Even an inpatient unit can be more gratifying than ED work.

 

[Orgone]

It's not what I spend the most of my time doing, but the patients I remember the most (in a good way) have been through outpatient work with the schizophrenia population. Many of them are frustrating, but with some you can develop a relationship and trust over time to where they actually will start taking medications, and make big transformations in their lives. The importance of the personal relationship can't be overemphasized.

 

[Armadillos]

Personally I really like doing outpatient work with folks with schizophrenia or bipolar 1. My patients are often chronic and very frequently hospitalized by the nature of their illness, but that doesn’t mean we aren’t helping them or making a difference.

From a medical/psychiatric standpoint it’s incredible how a LAI or clozapine can change some folks lives. Also from a humanitarian perspective, I do a lot of seemingly minor “case management” type stuff for my patients which take me maybe 1 phone call and 2 minutes of time due to being a physician, but would have taken their family a month to figure out.

My days are never boring and while there are always frustrating or seemingly hopeless cases, imagine how much more hopeless it would be to be that patient or family if they didn’t have a psychiatrist along side to help them cope with these illnesses.

 

[whopper]

Every area of it I've seen has it's ups and down.

Outpatient: It's easier in the sense that you don't see as many severe cases but you see a lot more Axis II pathologies that can get downright annoying especially after seeing these patients over the long-run. In inpatient, yeah they got Axis II disorders, but you know that you're not going to do anything to get those better unless it's very long-term inpatient. Of course I didn't just ignore those Axis II pathologies. I referred them to therapy or told them I could work on it with them but many of them had no intention of working on them. Okay fine, but those Axis II pathologies then end up biting me on the ass. E.g. they keep calling my receptionist like 5x a day over nothing relevant other than their temper tantrum or something like that.

A lot of patients are bad patients. I don't mean this in terms of medical pathology, I mean this in terms of them getting annoying when not fulfilling their obligations such as showing up on time, paying their bills etc. I frequently terminate patients because they don't pay a bill and I know darned well they can pay for it (e.g. one patient of mine made over $1 million a year and didn't pay for any of his bills). Some patients come in and don't give you any decent information.
E.g. Me: Do you feel an difference so far on this new medication?
Patient: Um, well kind of. But you know. Maybe not.
Me: Can you be more specific?
Patient: Well you know. It's like that.
Me: No I don't know that's why I'm asking you.
Patient: You're the doctor.
Me: That doesn't answer the original question that you still haven't answered. Do you feel any difference on this medication? If you don't know you can simply just say I don't know.
Patient: Well you know. It's like that.

Continues for about 7 minutes with me not knowing at all if the medication is having any effect whatsoever. I've had patients where my internal voice has sometimes asked me if this was really Sasha Baron Cohen trying to piss me off so he could get a gotcha moment on me on camera. And when a schizophrenic patient does this I don't mind cause heck it's schizophrenia. I'm talking some patient pulling the above and pretty much making the session like pulling teeth and not due to a psych illness.

The nice thing is you can terminate patients. I've eliminated most patients that freaking annoyed the heck out of me so it's relatively smooth sailing. I do give multiple chances before I terminate them because I want to be sure for myself that this is really something within the patient's control unless they do something just extremely outrageous.

ED: Each patient is likely new, and the the ones that aren't are usually frequent flyers that also has it's effect on morale. Lots of malingerers you need to kick out.

Inpatient: You got to spend usually on average about 30 minutes a day dealing with BS such as malingerers, kicking them out. You might have bad staff members. You're in a situation where you need to work with a team, some of those team-members might be terrible and outside your power to have removed.

Forensic: Lots of the time I've known the mental health law even more so than the judge and sometimes the judge makes incorrect legal judgments but you can only sit there and accept it because if you try to correct him/her in court you can be charged with contempt of court.

Addiction: The patient will only get better if they want to get better. Often times I get the patient's family member calling me and yelling at me blaming me for the patient not getting better when the patient even openly declared they have no intention of going sober, and in fact was only seeing me because the family member threatened the patient with something (e.g. cut off from the trust-fund). Due to the patient not signing and HIPAA forms for this family member I respond that I cannot give any information out and they continue to yell at me.

There have been a few times where I told the patient's family member not to call my office unless they are to provide any relevant information that can help me to help the patient otherwise don't call me and if they continue I will take legal action against that person because they called so many times in such a disruptive manner.

Notice I haven't complained about patients being sick in an Axis I manner. I don't mind patients needing time especially if they are sick, after all that's what our field is all about. Tolerating annoyance, now that's different.

 

[FrasierMD]

I vote Geriatrics, Consults, and TBI/Neuropsych! The uniting themes between these for me are 1) tons of overlap with neurology and medicine, meaning you can stay sharp on neuro exam, imaging, general medicine 2) formulations are often complex across the biologic, psychologic, and social domains, 3) particularly with consults, tons of variety with new cases daily — makes for a fun teaching environment and 4) treatment plans are rarely singular in nature, often requiring medications, home assessments, pt/ot, neuropsych interpretation, eeg, structural/functional imaging, LPs, rehabilitation, and on and on!

 

[whopper]

I didn't like geriatric for the following.
Dementia: you get very few wins. The medications we have these days to treat dementia aren't very good and usually don't lead to a good outcome, only slowing the bad outcome or causing slight improvement. You also get the patient's family expecting you to spend more time with them than with the patient. Listen, I get it that patient's family's are in need of therapy cause this is very traumatic for them but they are not your patients and the structure doesn't afford us to spend time with the family and give them separate treatment.

IMHO in such cases the family should have a separate therapist to help them deal with this, but if you refer them to one they often times won't get one and expect you to do it for them as a freebie despite that this is now how the system works, nor do you have the time to do so.

Another problem with geriatric is you often times got to work with an IM doctor and if that IM doctor isn't any good you're essentially practicing with one arm tied behind your back. I've had this happen several times. E.g. the pt's BP is 186/120 (not White Coat Syndrome, it's consistently like this) and the pt meets criteria of HTN crisis and the IM doctor does nothing.

While I did geriatric this problem wasn't like a 1 in 100 thing but about a 50-50 thing.

Of course there's plenty of pros. I'm mostly just ranting here. What I noticed while I was in the university was enjoying the versatility of being able to do one type of medicine and switch out with another doctor after one area got tiresome, so when you do the other thing (e.g. switch from inpt to ER) it kept things fresh and new.

 

[Dharma]

Not necessarily a subspecialty (despite a recent push to make it such), but I would say I enjoy psychotherapy the most given that many appear to have benefited (especially relative to what I have personally seen in clinic with medication management of depression, anxiety, and confounding factors such as personality disorders). I always joke and say that if I hit the lotto tomorrow (or when I have the capital in the future), I would/will bail on this predominate medical model of modern psychiatry (yes, I think many are trying to hard to "fit in" with rest of "medicine"), go all-in at an analytical institute, make the most of that, set up shop, and leave the vast majority of Rx to someone else.

 

[Sushirolls]

Addiction: Because the spread from dysfunction to function is so vast especially with buprenorphine and MAT.
Neurostimulation: Because with ECT, similar concept, people go from years of depression, even on disability, to now being able to function. One patient was like, 'shoot, I'm 50's and now I feel well and can actually work, what the heck do I do now that I'm not just sitting on couch at home?' Or family members who are delighted to get grandpa back from the severe depression/psychosis.

Least: C&L, because its essentially a service that exists because of bureacracy, i.e. patient needs inpatient psych, just had SA, and primary service doesn't want to arrange the transfer or write the state required hold documents. IMO, all of C/L can be done either by the primary service or a SW. Most of the time its just an antipsychotic writing service (despite more literature coming out saying they don't anything for behavioral disturbances or delirium and probably better off not using them). Or you start zoloft 25/50mg. Most of the time the primary service doesn't read the notes. Or its a rubber stamp template for delirum; reduce opioids, avoid anticholinergics, don't use benzos (some data debates that one), don't use antihistamines, find the under lying etiology, reduce polypharmacy, etc. Conversion disorders are essentially consults because neurology doesn't know how to talk to their patients and point them towards a therapist... Crying/sad, surgeons don't want to spend 5 extra minutes of empathy. Capacity consults, primary service is capable of doing, doesn't require a psychiatrist to do it. C/L is a complete waste of psychiatrist's time. All the complex cases or medical zebras, don't require psychiatry, and psychiatry is merely a passive observer to the services that actually treat or manage it. The only condition I could think of that really could be a possible C/L case that warrants such a service is NMS or malignant catatonia requiring bedside ECT in ICU. Transplant C/L is worthy of their title, but that's a different beast. /rant