Trepidation

Since most of my readers (at present) are not psychiatrists, I thought it'd be good to start with that perennial question, "So what do you do, exactly, as a psychiatrist?" Since the next four years are supposed to be a comprehensive preparation for independent practice, the answer is really "a little bit of everything". But, at least for the next year, the answer is "one month of ER, one month of medical consults, two months of inpatient pediatrics, two months of neurology, and six to seven months of acute inpatient psychiatry". (A month is 28 days, hence why we have thirteen of them.) Like most intern years, it's heavily focused on the inpatient (people coming in to a hospital, as opposed to being in a clinic) management of acute (seriously ill, potentially life-threatening, fixable in a relatively short timeframe) conditions. In my case, that starts with acute inpatient psychiatry at the main University of Washington hospital.

Most of you will be lucky enough never to see the inside of an inpatient psychiatric unit. In some ways, it's like the other inpatient medical units you may be familiar with. Patients see their resident (and med student, if they have one) in the early morning, get seen again by the whole team (including attending physician) in mid-morning, have medication adjustments, tests, etc. ordered in the late morning/early afternoon, and then spend the rest of the day hanging out while waiting for those orders to be implemented. On a given day, one or two people get discharged, and others come in to take their place; the residents spend their afternoons doing the basic intake exams and paperwork required to keep that machine running.

Psych units have two big differences that still leave me a little nervous (hence the title of the post). First, instead of a large team, psychiatric inpatient care generally means one attending, one junior resident (me), and maybe one med student. Everything else is nurses, therapists, patient care techs[1], social workers, and other extremely helpful support personnel. In practical terms, that means that for somewhere between eight and twelve patients, I'm where the buck stops. I certainly get guidance and supervision in diagnosing them and picking the right meds, but the goal is for me to take the lead and be the primary doctor[2].

On a medicine floor, I'm very comfortable in that role. Yes, I've been away from the wards for six months, but the basic treatment for heart attacks, pneumonia, COPD[3], and heart failure hasn't changed much. Plus, I've had those drilled into me on so many rotations that I think I can diagnose and manage the average case competently. Not excellently; I'm still at the "cookbook medicine" level, and if they've got multiple other diseases the algorithms start to break down. Nevertheless, competently. I don't feel like I'm there with psychiatric disorders. I've had a whopping two months of psychiatric training during medical school, of which the most recent was over a year ago. I do still have a gut feeling for the diagnostic axes, but the full criteria and drugs beyond the first-line obvious choices continue to elude me.

Ultimately, this is what every intern feels just before he/she starts (except the ones who are delusional about their own intellect; those guys end up killing people). It will pass, about the time I'm scheduled to rotate to another service. Moreover, it keeps me humble, which is a good thing. That doesn't make the butterflies stop flapping in my stomach.

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[1] The artist formerly known as "orderly".

[2] In theory; different attendings are variable in the degree of autonomy allowed, and I'm sure I'll be on a short leash the first month or so.

[3] Chronic Obstructive Pulmonary Disease, fancy doctor talk for "done smoked too much and lungs have given up".