Here's a run-down of what my day-to-day schedule looked like on Inpatient Psychiatry:
- 7:45: Arrive to the inpatient hospital and read up on patients
- 8:00 - 9:00: Morning report with all the providers and the DE (determine involuntary psychiatry holds placed on patients), rounding on patients in the conference room
- 9:00 - 12:00: Check on patients, admit new patients
- 12:00 - 1:00: Lunch
- 1:00 - 3:30: Write progress notes or H&Ps
Big Takeways from this rotation:
Do you love the specialty or the people working in it? I absolutely adored my preceptors, and the lifestyle was so nice and such a change of pace from Pediatrics. We usually wrapped up work around 2 or 3PM everyday, and after work we would all go to dinner, see a movie, or go to a workout class. We were together all day everyday and I had so much fun with them, I truly made life-long friends. With that, it was important to ask myself if I enjoyed the specialty, or the people around me. I had to separate the two and figure out if I loved the work I was doing with patients as well. Luckily, I found I loved that too.
How can I expect my patients to have confidence in me, if I was still struggling with having it in myself? When I was in first year, I remember saying to someone, oh I'm just a student doctor. But in the not so distant future, I will be THE doctor, and to fall back on this statement is doing myself a disservice. The fact that I was seeing 5-10 patients a day by myself, doing their full admissions for hours, and being in charge of their care for weeks at a time, I was in the role of the doctor and was liable to uphold the patient-doctor relationship. My preceptor trusted me and my judgment, and would ask me what to do next. So I had to own that responsibility and have more confidence. The fact that my preceptors had so much faith in me was really validating and made me reflect on how I needed to have more of it myself.
Are you asking questions to check it off a to do list, or are you really listening? Psychiatry is a specialty where you will learn intimate details of your patients' lives, so when they disclose something personal, make sure to pause and acknowledge that. I understand sometimes it can be uncomfortable or this may be the first time you have ever heard about sexual assault or physical abuse, but please take the time to validate your patients instead of brushing it aside and moving on to the next question.
Avoid statements like "I'm sorry" try instead something like "I hear you," or "thank you so much for sharing that with me and for trusting me with this information." If someone is unloading a lot, I would say something like "only one of those things is a lot for anyone to handle, let alone everything at once. Your reaction is completely valid, and you are so strong."
Work-life balance. Meeting with the patients could be really draining and emotionally taxing. The majority of the hospitalized psychiatry patients have trauma, and a lot of that includes physical and sexual abuse. I found some patient encounters very challenging and triggering at times. I would find myself fighting back tears a LOT. It's a privilege that patients trust us enough to be so vulnerable, but as an empath, I had a hard time not bringing it home with me. Most days I would get home and didn't have the energy to do much else. And that's okay, I knew I needed that. It is so important to remember your own mental health and take the time when you need it, if that means not studying for the shelf every day, then so be it.
Trust your gut. If you ever feel you're in danger or in a situation where you don't feel safe and are alone with a patient, trust that. Keep doors open, leave the room when you need to. ALWAYS bring a panic button with you if you are seeing patients alone. This happened to me maybe only once or twice when I could feel the patient's hostility, and I learned to trust that "spidey sense," as my preceptor would call it.
Resources used for wards:
List of questions for Progress notes that I made and would print out and bring to every patient check in. Feel free to print out and bring on your rotation.
Maxwell Resource Guide has a good Mental Status Exam
If you're considering Psychiatry as a specialty, I recommend buying the DSM-V
Resources used for the shelf exam:
Emma Holliday Psychiatry:
First Aid Step 2 CK (psychiatry section)
Qbanks: UWorld, Comquest, Combank
Here is a study guide that I made: Psych Rotation Study Guide
Attire:
Inpatient: business casual -- I recommend not wearing a white coats because there are plenty of patients who are paranoid or have a mistrust of psychiatrists.
What to bring:
ID Badge
Keys for inpatient hospital
Pens
Clipboard helpful because I try to actively listen and jot down notes here and there, not typing away on a keyboard
What to read up on/common topics on shelf exam (most are on my study guide)
DSM-V definition of disorders and the timelines of each
Screens
Neurotransmitters effected in pathologies (dementia, Alzheimers, depression etc)
First line drug treatments and their side effects (ie: weight gain, sexual dysfunction, contraindicated in eating disorders)
Types of therapies (ie CBT vs psychotherapy vs DBT)
Treatment in geriatrics and pediatrics
Recommendations
Learn the brand names of drugs. I've created a list of the common brand name drugs (with generic name in parenthesis) that we used inpatient:
Antipsychotics:
Zyprexa (Olanzapine)
Abilify (Aripiprazole)
SSRI
Celexa (citalopram)
Lexapro (escitalopram)
Luvox (fluvoxamine)
Paxil (paroxetine)
Prozac (fluoxetine)
Zoloft (sertraline)
SNRIs
Effexor (venlafaxine)
Cymbalta (duloxetine)
Anxiolytics
Ativan (lorazepam)
BuSpar (buspirone)
Inderal (propranolol)
Klonopin (clonazepam)
Librium (chlordiazepoxide)
Serax (oxazepam)
Tenormin (atenolol)
Tranxene (clorazepate)
Valium (diazepam)
Xanax (alprazolam)
Mood stabilizers
Lamictal (lamotrigine)
Lithium
Depakote
Stimulants
Adderall (amphetamine and dextroamphetamine)
Dexedrine (dextroamphetamine)
Ritalin (methylphenidate)
Mental Status Exam: Motor behavior: no psychomotor agitation or retardation, no involuntary or abnormal movements Speech: normal volume, spontaneity, rate, and intonation Attitude: cooperative to exam Mood: “quote patient directly” Affect: congruent with mood, normal intensity, normal variation, full range, appropriate reactivity Thought process: coherent, logical, linear and goal directed without signs of a formal thought disorder
Thought content: endorses passive SI, denies HI or other aggressive impulses, no indication of persecutory content or delusional content Perception: denies auditory, visual or tactile hallucinations Sensorium: awake, alert, attentive Orientation: oriented to person, place, date, floor of hospital
3 word recall: did not formally test Insight: fair Judgment: fair
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