Discerning Psychiatry

I just finished by NBME (National Board of Medical Examiners' "shelf exam," the final exam we take after each rotation) for Psychiatry. Earlier this week, I had my OSCE (Observed Standardized Clinical Encounter), which consisted of two thirty-minute SP encounters. Psych is over!

In the past six weeks, I have seen 97 different people in a total of 132 visits, 24 of which were "full involvement," including history, physical, differential diagnosis, and treatment. Of note, 40 of my encounters were with males and 92 were with females. This is probably because 1) More women have psych issues and 2) I selectively picked up women's charts when I could. Also of note, there was only a single Asian patient; all the rest were black (30) or white (93). The largest age group represented were the 45-to-60-year-olds, but that's also slightly off probably because I had to guess on some people.

So, what to think of psych? I'm not sure, to be honest. The hours were decent and I enjoyed talking with patients and being part of their care. It was hard to see so much suffering, but that wasn't demoralizing until I got really tired toward the end. I actually felt a little energized by the opportunity to console people in such dark places. (It was unsatisfying not to have continuity of care with those people!)

Toward the end of the rotation, I had a pretty bad week because I got really fed up with the way mental healthcare works, at least in my county. Managed care and third-party payors seem to have really goofed up care. In my grandparents' generation, people were hospitalized for a year, on average. In the hospital I just finished working at, the average stay is 7-10 days; four weeks for people with really good insurance and the older patients on the geriatric unit, who have no other place to go. It's the worst for the poor and the elderly, who should have special privilege.

I was really upset by the amount of control the insurance companies had over the patients' stays. One patient I saw needed to stay but couldn't, and we pretty much had to turn her out, tearful and still needing help. Another patient I saw couldn't get an outside placement at a nursing home unless the doctors made it look like they'd done something to change his status, so his medications were changed (increased) without need.

To be fair to psych, I was cutting back on my eight-hours of sleep, which I've had since before college. And also to be fair to psych, I wasn't getting a lot of exercise. So, the daily schedule during Psych:
5:30am: wake up, eat breakfast so that we keep the fast!
6:10am: leave for Mass
6:30am: Mass, Morning Prayer, and meditation
8:00am to 12:00pm: work at inpatient psychiatric hospital. Midday Prayer if possible! Commute to...
1:00pm-5:00pm: observe at outpatient psychiatry practice, or sometimes lectures, or (four times) a shift in the admitting department until 11:00pm
6:30pm: home, dinner, Evening Prayer. I'd study sometimes in the evenings, or hang out with my family. Formation once a week!
10:00pm: Night prayer and bed.


So, things I liked about psych:

1. talking with people about serious stuff
2. some of the faculty
3. being independent: writing notes, writing prescriptions (even though my signature still doesn't count)

Things I didn't like about psych:

1. talking with people about serious stuff ALL THE TIME.
2. the rest of the faculty (was it just my hyperawareness of abnormal psychology or did some of them have mental illnesses?)
3. the insurance companies' control
4. the feeling that none of the problems were actually fixed by the doctor: the therapist did most of the real work and the helpful work (chemicals are great but not as good as therapy, it seems), and the past problems were past and it was too late to prevent them.
5. not being able to answer people's questions about their conditions and medications.
6. the slightly demeaning way in which all the doctors talked about the patients

So, some of those (e.g. #2 on the pro's and #4 on con's) are just effects of being a medical student on her first rotation. And some of them are purely situational (the faculty ones). And although I enjoyed talking with people, I got a little fatigued by the end of the six weeks because of the nature of the pathology, the payment system, and the mounting feeling like psychiatry isn't the kind of work I want to do. The attitude it engenders towards patients (#6) and the unhelpfulness (#4) is diametrically opposite to my hopes for myself.

We'll see what family medicine has to offer. Here we go!