Clinical Year: Psychiatry

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So I'm going to be honest.  Psych was not my favorite rotation.  Actually, it was my least favorite, and I'll tell you why, but this was definitely the rotation that I most dreaded going to everyday.  I spent all 4 weeks of my rotation on the in-patient psych ward at the hospital, and a whole month was way too long to just be in the locked unit.  Patients in the hospital are sometimes there for an extremely long time, and so there were a couple of patients that I followed the whole time without many changes, and I just don't feel like I got the best exposure to psychiatry.  That influenced my opinion of the field a lot, and I wish I had some outpatient experience mixed in as well.  Even the med students only spend 2 weeks on in-patient at a time, and spend other time in outpatient, pediatrics, or the ER.  Anyways, enough of my rant, now on to the details of my time in psychiatry.

It was a little nerve-wracking going into a unit of the hospital with 2 locked doors that required codes, but it's necessary for the safety of the patients. I spent a lot of time in the resident's room, and I spent a lot of time during this rotation on the phone.  This was my first rotation where I was working with med students and residents.  The med students that were there only stayed for my first week, but they were so helpful!  This was my first rotation using electronic medical records (EMR) since my family medicine rotation was still using paper charts, and the med guys showed me the ropes and were a big help to me.  Residents were a different story.  The first resident I was assigned to was actually a PA for about 12 years before deciding to go to medical school, and she was a little frustrating at times and would give me pointless things to do, like finding colleges for her daughter to apply to. Not super beneficial for my education.  But as bad as I though she was, it was nothing compared to the resident I was with for the last week.  She was extremely unreasonable and not helpful at all, so that was a challenge, and I was glad to be done!  I met some very nice residents, but I did not get to work with them personally.

My attending on psych was great.  He was very patient and a good teacher.  What's interesting about doing a rotation at a teaching hospital is that the attending is not around very much.  We would arrive around 7-7:30 am and go see our assigned patients and then the doctor would show up to round at 9.  Rounds on psych were also a little different.  We would sit in a big conference room (attending, residents, students, social worker) and bring the patients in one at a time to discuss how they were doing, any changes that needed to be made in medications, and possible discharge plans.  After rounds, we would put the plans into action, and like I said above, that typically meant a lot of phone calls.  There has to be a lot of communication with family members if considering discharge to ensure the patient will be safe and have support to continue medications and make it to follow up appointments.  One of the hardest parts of psychiatry is establishing discharge because the patient has to have somewhere to go. If they do not have a home or anyone willing to take them in, then the social workers try to find a shelter or halfway home for them to go to.

I saw some extremely interesting, and very sad, cases while on psychiatry.  I think for me personally it was just too emotionally draining.  There was one weekend that I felt very depressed and I think it was just the environment that I was surrounded by.

The second day I was there, a patient actually committed suicide and that was extremely troubling to all of us there including providers, students, and patients.  There are measures in place to prevent something like that from happening, but if a person is determined enough they will find a way.  There was a lot of procedure to go through after that and a patient limit was started on the unit, which decreased the amount of patients we got to care for.

There was an 18 year old who had been started on antidepressants before leaving for college, and 2 weeks into school called her parents with serious thoughts of hurting her roommate.  That progressed to thoughts of hurting other people, including her family and herself, and she ended up on the in-patient unit.  The new medication and stress of starting school had basically initiated a psychotic break.  She was experiencing very intense hallucinations.  For example, at one point the medical student and I were questioning her, and he asked if she was having any violent thoughts.  Her response was that she was imagining taking the pen out of his shirt pocket and stabbing him in the throat.  That was sobering and made me realize this was a serious place to be and it really broke my heart to see such a young, pretty girl struggling so much.  She was very sensitive to medications and one of the medications she was started on actually caused her to have tardive dyskinesia.

It was also interesting seeing how patients can work the system.  There was an Asberger's patient who treated his time in the ward as a vacation.  He found out that if he said he was suicidal, they would have to admit him and then he would keep saying it while he was there.  Patients would also occasionally come in if they needed a place to hide out, like if they owed someone money.  The attendings were good at recognizing these patients and finding out their motive.

Blueprints Psychiatry (Blueprints Series)
By Michael J. Murphy, Ronald L. Cowan MD PhD

I also got to see great cases of schizophrenia and bipolar disorder, as well as drug and alcohol abuse.  I did learn a lot, and one of the good things about psych is that the test was very straight forward.  I feel like psych is easier to learn than some other areas.  The hardest part is the medications for sure!  The book I used the most was Blueprints Psychiatry, and I would recommend doing as many practice questions as possible.

My frustrations with psychiatry came from only seeing in-patient and feeling so limited by medications.  Some of the patients were on so much medicine, and it was very hard for me to see the effectiveness in the time I was there.  At least one person that I graduated with is working in psychiatry and I think it takes a very strong personality and someone who does not let their emotions get involved to work in this field.  I would love to hear about some of your experiences in psychiatry or answer any questions you may have!

Here is a blog post of another student's experiences while on her psych rotation.