Friday, October 01, 2010

Psych redux

Today was my last day of psych, and I was sorry to see it go. I'm going to try and figure out why (mini-psychoanalysis, I guess) so that, in a year from now, I can remember the pros and cons about each of my rotations.

I think part of me liked it because it wasn't the lab. That makes any rotation look good! There were a few low points (one in a minute), but overall, I looked forward to going into work every day. I learned a lot, I thought my team was great, and I feel like I came out of the rotation one baby step closer to being a doctor. Of course, I also liked being an armchair analyst; I listened to lectures and thought, "Oh, family member X must be borderline! Friend Y is totally bipolar!" (relationships changed to protect the innocent!). I didn't mean this in a judgmental way--it was more in line with, "wow, if they were actually treated for this, I wonder how much better their life would be!"

Here's the story on the worst day I had. On Tuesday, I really thought I was going to end up sitting in my car, crying, by the end of the day. The psych ward was extremely busy. I had a new patient whose note needed to be in the computer by 2:45. Rounds went till 12:30, then the ROS/mini mental/physical exam went till 1. We had case conference that was scheduled from 1-2, but it actually went till 2:30. I appreciate that the psychiatrist was letting a manic patient be tangential, but all I could do was sit there and fixate on how in the world I was going to write a huge admission note by 2:45. It was 2:40 by the time I got back to my desk, and when I called my attending to tell her the note wouldn't be done on time, she wasn't there. I checked my email to see if she had tried to catch me that way; she hadn't, but I had a bunch of emails from my lab PI about thesis stuff, and I had emails from Tim that day care had called about Josh.

I just felt very overwhelmed. I called Tim quickly, and apparently day care noticed a rash on Josh and wanted him to go home. He didn't have a fever, he was eating, he was sleeping, and he was otherwise acting normal. It sounded like the rash was just where his sleeper had been touching his skin. Tim, Sophie, and I all have sensitive skin; I told Tim to tell them to put him in another outfit and call if things got worse. I felt terrible, like I was abandoning my baby. Tim had meetings all afternoon, and I was crazy busy. So, we agreed that as long as Josh seemed ok, we'd let it go.

I couldn't even respond to the lab emails. My blood pressure goes up every time I get something from my old PI. It's not personal--it's just that everything is made to sound like a total emergency. I keep telling myself that I don't have to have my thesis to the committee until the end of October. That doesn't give me a pass on finishing it,  but it doesn't have to happen this instant. I can't seem to impress that upon my boss, so I have stopped trying.

It did take me a long time to write the admission note. I was so anxious about it being late that I gave myself a headache. Of course, it could have also been that I had not eaten or peed all day (which is normal--I didn't get a chance to eat lunch on the vast majority of the days I was there). When I finally heard back from my attending, she said it wasn't a big deal that the note wasn't in. The goal is to have the psych note in within 24 hrs of admission onto the ward. Since we only see patients on morning rounds, that meant that if someone gets admitted after about 11 AM, we don't see them till the next day. The nurses see them, obviously, but the official note doesn't go in. But, my attending wasn't worried about it, so I calmed myself down about it. By the time that note, all my other notes and orders, and patient family calls were done, I had just enough time to review them with my attending before she left. I got in my car, took a deep breath, and prayed that I wouldn't have another day like that for a while.

That was really my personal low on this rotation, but looking back, most of the anxiety was self-produced or outside the rotation. I didn't want to let my team and the patient down by not having my note done on time. That led to me staring at the clock (and unable to focus) during case conference. That should have been my only stress of the day. Once I was sure Josh was fine (and Tim agreed to be backup in case he did have to be rescued), I should've let that go. And the lab stuff--good God, the lab stuff. The emails on Wednesday were even worse than Tuesday--we got the galley proofs back, and although there were only two sentences they wanted clarification on, it somehow turned into this giant email back-and-forth with a ton of people. I was stressed about it, and then yesterday, I just let it go. My boss can sort everything out with the other author (who suddenly had a bunch of changes that he hadn't mentioned before). I just let it go.

Today, after letting go of the lab stuff, having no kid health concerns, and knowing I wasn't going to have an admission on team today, I was able to relax and enjoy my last day on the wards. I spoke to the team psychologist, social worker, resident, nurse specialist, and nurse practitioner, and they all encouraged me to think about psychiatry. I know this is fairly common, but they all talked to me individually and said they thought I was a great fit for it. The nurse practitioner said to consider the VA as an employer too--she was a single mom of two kids, and she said the VA is great about flexibility. She also said the health care and retirement packages more than made up for the lower pay versus private practice. She thought VA psych would be a great fit for me, if I wanted to consider it.

I met with my attending later, and she said many of the same things. She thought that since I was a bit older, and a mom, I had more insight into personal dynamics. She thought I had a knack for dealing with the psych patients. She didn't push me to commit to anything--she just suggested that, in general, I do some introspective searching and figure out what makes me happy. We talked for quite a bit of time. I agreed with her on a lot of points--like the fact that the goal isn't to make the most money or get into the most prestigious residency/fellowship, just to prove that you can. The goal is to find a job that you enjoy going to every day. If that's psych, great. If not, find something I like. We talked about knowing yourself and what is a good fit.

So that's what I am thinking about now. Honestly, I had not considered psych as an option before this rotation. I enjoyed the committee (they called it the "mind" committee) in medical school. I enjoyed the general psychology class I took in college. But I was not thrilled about the inpatient psych ward. I've experienced being a visitor on these wards, and I was always intimidated. I'm not going to say that I think living in a psych ward would be fun--please! let's be realistic. It sucks to be a patient on a psych ward (although most of these residents have asked at one point if they could live here--beats the streets). But, most of these patients make progress while they are here. Many, if not most, of them will come back. But you help them, you see them improve, and when they are ready, you send them out. If they come back, it's because of their disease. People with chronic medical diseases can have multiple hospitalizations. Psych patients shouldn't be stigmatized because their diseases bring them back to the hospital. Many patients go years between hospitalizations. There are a few who boomerang, but not all. These people get better slowly--but most of them can manage their disease on an outpatient basis.

Things that I liked:
  • the patient contact. I really enjoyed the time we are given to talk to patients. I'd like to spend some time in the afternoons with new patients, to maybe get a developmental history instead of just a general past psych history. But this part is fun.
  • the team concept. Not every psych ward works like this, but I loved that there are so many people with different backgrounds working collaboratively to help the patient.
  • the underlying psychology. I love thinking about the mind. We had a great lecture on psychodynamics of depressions (id/ego/superego stuff). I don't necessarily agree with all of it, but I do think the mind has its own ways of processing information that differs from person to person.
  • the nature vs. nurture debate. This is one of the few areas of medicine in which we still know precious little about the actual biology of the diseases. For instance, it is known that there is a genetic component to psychiatric diseases, but why do some people develop the disease and others don't? I think there is such potential for research and understanding--which would also increase treatment options (and maybe even prevention.)
  • the ability to watch a patient improve. So many of these people--especially the schizophrenics--can improve when they are on the right medications. Most of the admissions were about a week long, and in that time, some of the patients were drastically better.
  • the lifestyle. Let's be clear: I worked ~8 to ~5 every day. Some days were longer, not many were shorter. But for third year medical school, this is AWESOME. This will be the easiest rotation, schedule-wise, that I will probably have. As I said, you are very busy during that period. But being able to be home by dinner? That's awesome
  • it's fun. It's like playing detective. What's their diagnosis? What is the best plan for treatment? If X didn't work, what should we try next?
  • training is 4 years after graduation, versus 6 (3 medicine + 3 fellowship) for most specialties.
  • Pay. Again, anything is more than what I make as a student. And the fact is, psychiatrists make less than internists and about what pediatricians make. The amount varied, but the info I found was that the average is about $175,000. That's less than a cardiologist makes (which averages about $300,000, but can go higher). But come one now. That's almost ten times what I am making now, and it is freaking six figures. Basically, anything that is above the student stipend I am making now is a CRAPLOAD of money.  Really can't complain.
  • This is a negative for most of medicine as a whole, but there is very little "curing" of people. Many of these patients have their lives improved dramatically. And I've been told that on the outpatient side, many people return to normal lives with medication + therapy. But for this inpatient crowd, most of these people will be back in the hospital, mostly due to...
  • noncompliance. This is noncompliance in general--mostly with medications, but also with substance abuse. Some of the patients don't understand the disease and therefore don't understand the medication. Some are paranoid. Some don't like the side effects. Some can't afford the meds. And for substance abuse, most can't keep with it (alcohol dependence has an 80% failure rate for treatment). This is sad, but a big part of treatment is getting people to own their role in the treatment of their disease.
  • There is no diagnostic test, procedure, or lab for most of these diseases. When you diagnose something, it's all you. You can ask a colleague for another opinion. But basically, you have what the patient is telling you, what you can gather from other people's collateral histories of the patient, and that's it. You have to be confident enough in your estimation to discharge someone who threatened suicide--are you sure they are better? Is this person really just looking for attention, or are they dangerous? Those are big responsibilities.
For me, I think psych stays on the list. I enjoyed my time in outpatient medicine when I was still in the lab, so medicine (and a specialty) may still be the frontrunners. But to my surprise, I think psych is running a strong #2 at this point. We'll have to see how I feel in the future.

Neurology is my next rotation, and I think I can safely say that it is not on the short list in terms of a career. I hated neuro in med school. This is one month that I am just going to try and get through...

On another note, I came across this post when I was googling psych stuff the other day. Very interesting:

The ten biggest mistakes psychiatrists make