5 ms·

Reflections from the Halfway Point: Lessons from a psychiatry residency

74 points by Hooke 11y ago

jtfairbank 11y ago
- How difficult is the administration side of the residency? - Do you or your chiefs have to do a lot of work to manage your call or patient appointments? - Is it similar to internal medicine, where you have rotations and also ambulatory / continuity clinics? Or is most of your work in clinic with patients? Working on a residency scheduling startup (https://reschedulemed.com https://reschedulemed.com). Would appreciate any feedback you have. :)
elliotec 11y ago
A lot of the sentiment here is why I chose to go into software development rather than psychiatry, apart from the whole money vs med school argument. Great post.
marincounty 11y ago
Congrats on finishing medical school, and most of your residency. That said, I briefly read your post, and while I admire your optimism, and trust in the system; Psychiatry is currently trying to pull itself out of a deep hole of bad science, bad studies, faulty theories, etc. I'm too tired to list my gripes with the Art of Psychiatry, please don't just set up shop somewhere and make a comfortable income. Yes, set up shop. Yes, make a comfortable living. But, please there's a reason some doctors are prescribing offlabel, and taking more risks than what your being taught. The tried and true methods are not working, or working so closely to placebo it's beyond ironic. Seasoned Psychiatrists(with a conscious) are frustrated with the currently horrid cure rates, with the "tried and trued" traditional medications. They are tired of finding all those theories are not holding up. They are just tired. Right now you are seeing the really ill. When you get out and set up shop. Most of you time will be seeing a patient every 15-30 minutes. Your patients will be a lot like you(come from a good homes, but they had a breakdown usually in their twenties, or thirties. So many will be high achievers, but stopped dead by a breakdown.). You will find so many medications just don't seem to work. SSRI's just might be the biggest scam perpetuated on the medical profession in part by Eli Lilly? Right now, you must have realized Placebo will be the best tool in your arsenal? What I am trying to say is when you get out, and set up shop, most of your patients will come to you at the worst time of their lives. They will put a lot of confidence in your judgement. Many will be paying out of pocket. I'm not going to give a soon to be doctor much advice, but question the studies. Don't just chalk up the non-responsive to statistics. I'm not saying you should take heroic risks in trying to get the patient functioning again, but be honest. I don't see anything wrong with--Patient, "The medication, and therapy didn't work as I expected, but you will get better with time!". Be honest about the results of your profession, especially when any chance of placebo cure is long gone. In other words, don't make the patients life worse because you picked a particularly ineffective speciality. Oh, yes you will probally find yourself surrounded with other Psychiatrists, and they will encourage you to keep your head up high, and keep that income up; Don't abuse that magical transference on the poorer patients. (I think you get my drift?) I'll get hammered for this post, but as a former patient these are just my honest thoughts. Take care of your own health, and realize in the end--we are all in this mess toghther?
- bjwbell 11y ago
  FYI: He's done research on the efficacy of SSRI's, http://slatestarcodex.com/2014/07/07/ssris-much-more-than-you-wanted-to-know/ http://slatestarcodex.com/2014/07/07/ssris-much-more-than-yo....
  - marincounty 11y ago
    (1) Point me towards the studies that prove SSRI's are so much better than placebo in the sickest patients. I really want to change my mind, but when I read the literature-- it's almost like they just can't admit they were fooled? Plus--take away tri, and hetro-cyclic drugs--the arsenal of cures goes way down, along with patient count? There's a strong reason to protect anti-depressants? (2) "Eli Lilly, the company behind Prozac, originally saw an entirely different future for its new drug. It was first tested as a treatment for high blood pressure, which worked in some animals but not in humans. Plan B was as an anti-obesity agent, but this didn't hold up either. When tested on psychotic patients and those hospitalised with depression, LY110141 - by now named Fluoxetine - had no obvious benefit, with a number of patients getting worse. Finally, Eli Lilly tested it on mild depressives. Five recruits tried it; all five cheered up. By 1999, it was providing Eli Lilly with more than 25 per cent of its $10bn revenue." http://www.theguardian.com/society/2007/may/13/socialcare.medicineandhealth http://www.theguardian.com/society/2007/may/13/socialcare.me... (3) Hay--they might work? Too tired to debate!
    - marincounty 11y ago
      5 patients with mild depressives? Ironic? Dysthymia? Not the clinically depressed?
  - deleted 11y ago
    [deleted]
- ikeboy 11y ago
  >I'm not going to give a soon to be doctor much advice, but question the studies. Don't just chalk up the non-responsive to statistics. It's a bit ironic that you say this, considering that this guy has written a whole lot about statistics and their flaws. http://slatestarcodex.com/tag/statistics/ http://slatestarcodex.com/tag/statistics/
cerrelio 11y ago
This sounds similar to my stay in a psych ward after a suicide attempt brought on by a mixed episode (bipolar; was undiagnosed at the time, and was given an incorrect diagnosis of major depression by the admitting doctor). A psych ward is essentially a jail; not an unfashionably appointed hotel as the author suggests. The worst part is looking out the window and realizing you can't leave. I could bear the three schizophrenic cases who collectively screamed, danced and twitched catatonically. The borderline girl would shout that her father raped her and that she was in there because of a vengeful social worker. One girl tried to hang herself in the bathroom with strung together kotex. None of this was remotely bothersome in comparison to not having my freedom. Immediately after leaving the hospital I stopped taking my medication (Seroquel - for sleep, 200mg [this is off-label and 4 times the dose for insomnia], Prozac 20mg). It was causing me unbearable side effects. Despite being unmedicated and untreated, I was stable for 6 years until after moving up north. I became depressed again and was put on Zoloft. Zoloft triggered a prolonged hypomanic episode which doctors tried to treat with multiple medications over 4 months. It was a terrible time. Ultimately I told all the psychiatrists and doctors to shove off. I started using light (and darkness) therapy, because after examining my history all of my depressive episodes were in the winter. I never had any sort of disruptive manic episodes outside of the Zoloft incident. I also started exercising 4 times a week, which has largely protected me from any sort of depression in the winter (along with the lightbox). Psychiatry is closer to witchcraft than medical practice. It's a bumbling attempt to treat an organ we have yet to understand. I feel deeply sorry for anyone who has gone through the type of unnecessary suffering I experienced. There really needs to be stricter regulations and oversight of the practice, because it's in a shameful state.
anonfornow 11y ago
I am saddened that I have post this anonymously, but there is still a lot of stigma regarding mental health. Much of what the author says about the psych ward aligns with my limited experience as a patient, but, please, if you are suicidal, delusional, manic, uncontrollably angry, or paranoid, check yourself into the nearest emergency room. Even if you do not think you are threat, you can still physically harm yourself or others if you do not seek help. I speak from experience. The psych ward is there to get you stabilized and get attention quickly. But in my, again limited, experience, the state of inpatient psych treatment in the US is terrible, especially given the cost. If you want anecdotal evidence that something is deeply wrong with our health care system, try spending a week in a psych ward. But it is all we have right now, and spending time in the psych ward is still better than harming yourself. Sadly the outpatient system isn't much better. In many cities there is a chronic lack of psychiatrists. I think many Dr's have become jaded by the number of patients requesting treatment and can overlook more serious cases. Also, in my opinion, too many psychiatrists have become 'prescribers' and not involved enough with their patient's therapy. In which case they can loose touch with the effects of the medication being prescribed. I am Bipolar Type II, and, while treatable, it can be a very dangerous illness. It can wreak havoc with your life and the life of others.

74 points by Hooke 11y ago

- How difficult is the administration side of the residency? - Do you or your chiefs have to do a lot of work to manage your call or patient appointments? - Is it similar to internal medicine, where you have rotations and also ambulatory / continuity clinics? Or is most of your work in clinic with patients? Working on a residency scheduling startup (https://reschedulemed.com https://reschedulemed.com). Would appreciate any feedback you have. :)

elliotec 11y ago

A lot of the sentiment here is why I chose to go into software development rather than psychiatry, apart from the whole money vs med school argument. Great post.

marincounty 11y ago

Congrats on finishing medical school, and most of your residency. That said, I briefly read your post, and while I admire your optimism, and trust in the system; Psychiatry is currently trying to pull itself out of a deep hole of bad science, bad studies, faulty theories, etc. I'm too tired to list my gripes with the Art of Psychiatry, please don't just set up shop somewhere and make a comfortable income. Yes, set up shop. Yes, make a comfortable living. But, please there's a reason some doctors are prescribing offlabel, and taking more risks than what your being taught. The tried and true methods are not working, or working so closely to placebo it's beyond ironic. Seasoned Psychiatrists(with a conscious) are frustrated with the currently horrid cure rates, with the "tried and trued" traditional medications. They are tired of finding all those theories are not holding up. They are just tired. Right now you are seeing the really ill. When you get out and set up shop. Most of you time will be seeing a patient every 15-30 minutes. Your patients will be a lot like you(come from a good homes, but they had a breakdown usually in their twenties, or thirties. So many will be high achievers, but stopped dead by a breakdown.). You will find so many medications just don't seem to work. SSRI's just might be the biggest scam perpetuated on the medical profession in part by Eli Lilly? Right now, you must have realized Placebo will be the best tool in your arsenal? What I am trying to say is when you get out, and set up shop, most of your patients will come to you at the worst time of their lives. They will put a lot of confidence in your judgement. Many will be paying out of pocket. I'm not going to give a soon to be doctor much advice, but question the studies. Don't just chalk up the non-responsive to statistics. I'm not saying you should take heroic risks in trying to get the patient functioning again, but be honest. I don't see anything wrong with--Patient, "The medication, and therapy didn't work as I expected, but you will get better with time!". Be honest about the results of your profession, especially when any chance of placebo cure is long gone. In other words, don't make the patients life worse because you picked a particularly ineffective speciality. Oh, yes you will probally find yourself surrounded with other Psychiatrists, and they will encourage you to keep your head up high, and keep that income up; Don't abuse that magical transference on the poorer patients. (I think you get my drift?) I'll get hammered for this post, but as a former patient these are just my honest thoughts. Take care of your own health, and realize in the end--we are all in this mess toghther?

bjwbell 11y ago
FYI: He's done research on the efficacy of SSRI's, http://slatestarcodex.com/2014/07/07/ssris-much-more-than-you-wanted-to-know/ http://slatestarcodex.com/2014/07/07/ssris-much-more-than-yo....
- marincounty 11y ago
  (1) Point me towards the studies that prove SSRI's are so much better than placebo in the sickest patients. I really want to change my mind, but when I read the literature-- it's almost like they just can't admit they were fooled? Plus--take away tri, and hetro-cyclic drugs--the arsenal of cures goes way down, along with patient count? There's a strong reason to protect anti-depressants? (2) "Eli Lilly, the company behind Prozac, originally saw an entirely different future for its new drug. It was first tested as a treatment for high blood pressure, which worked in some animals but not in humans. Plan B was as an anti-obesity agent, but this didn't hold up either. When tested on psychotic patients and those hospitalised with depression, LY110141 - by now named Fluoxetine - had no obvious benefit, with a number of patients getting worse. Finally, Eli Lilly tested it on mild depressives. Five recruits tried it; all five cheered up. By 1999, it was providing Eli Lilly with more than 25 per cent of its $10bn revenue." http://www.theguardian.com/society/2007/may/13/socialcare.medicineandhealth http://www.theguardian.com/society/2007/may/13/socialcare.me... (3) Hay--they might work? Too tired to debate!
  - marincounty 11y ago
    5 patients with mild depressives? Ironic? Dysthymia? Not the clinically depressed?
- deleted 11y ago
  [deleted]
ikeboy 11y ago
>I'm not going to give a soon to be doctor much advice, but question the studies. Don't just chalk up the non-responsive to statistics. It's a bit ironic that you say this, considering that this guy has written a whole lot about statistics and their flaws. http://slatestarcodex.com/tag/statistics/ http://slatestarcodex.com/tag/statistics/

cerrelio 11y ago

This sounds similar to my stay in a psych ward after a suicide attempt brought on by a mixed episode (bipolar; was undiagnosed at the time, and was given an incorrect diagnosis of major depression by the admitting doctor). A psych ward is essentially a jail; not an unfashionably appointed hotel as the author suggests. The worst part is looking out the window and realizing you can't leave. I could bear the three schizophrenic cases who collectively screamed, danced and twitched catatonically. The borderline girl would shout that her father raped her and that she was in there because of a vengeful social worker. One girl tried to hang herself in the bathroom with strung together kotex. None of this was remotely bothersome in comparison to not having my freedom. Immediately after leaving the hospital I stopped taking my medication (Seroquel - for sleep, 200mg [this is off-label and 4 times the dose for insomnia], Prozac 20mg). It was causing me unbearable side effects. Despite being unmedicated and untreated, I was stable for 6 years until after moving up north. I became depressed again and was put on Zoloft. Zoloft triggered a prolonged hypomanic episode which doctors tried to treat with multiple medications over 4 months. It was a terrible time. Ultimately I told all the psychiatrists and doctors to shove off. I started using light (and darkness) therapy, because after examining my history all of my depressive episodes were in the winter. I never had any sort of disruptive manic episodes outside of the Zoloft incident. I also started exercising 4 times a week, which has largely protected me from any sort of depression in the winter (along with the lightbox). Psychiatry is closer to witchcraft than medical practice. It's a bumbling attempt to treat an organ we have yet to understand. I feel deeply sorry for anyone who has gone through the type of unnecessary suffering I experienced. There really needs to be stricter regulations and oversight of the practice, because it's in a shameful state.

anonfornow 11y ago

I am saddened that I have post this anonymously, but there is still a lot of stigma regarding mental health. Much of what the author says about the psych ward aligns with my limited experience as a patient, but, please, if you are suicidal, delusional, manic, uncontrollably angry, or paranoid, check yourself into the nearest emergency room. Even if you do not think you are threat, you can still physically harm yourself or others if you do not seek help. I speak from experience. The psych ward is there to get you stabilized and get attention quickly. But in my, again limited, experience, the state of inpatient psych treatment in the US is terrible, especially given the cost. If you want anecdotal evidence that something is deeply wrong with our health care system, try spending a week in a psych ward. But it is all we have right now, and spending time in the psych ward is still better than harming yourself. Sadly the outpatient system isn't much better. In many cities there is a chronic lack of psychiatrists. I think many Dr's have become jaded by the number of patients requesting treatment and can overlook more serious cases. Also, in my opinion, too many psychiatrists have become 'prescribers' and not involved enough with their patient's therapy. In which case they can loose touch with the effects of the medication being prescribed. I am Bipolar Type II, and, while treatable, it can be a very dangerous illness. It can wreak havoc with your life and the life of others.