I have been contacted by a number of psychiatry residents lately about this blog. Their comments are encouraging and remind me that practically everything that I post here is focused on practicing psychiatrists. especially people on the front lines being exploited by one government or healthcare corporation or the other. The comments also remind me that in retrospect residency and medical school was an exciting time and that there is really not much time between then and becoming a senior clinician. The vast majority of us negotiate that turf with very few problems but in some cases glaring mistakes are made that sidetrack careers or stop them in their tracks. There also seems to be an unnecessary amount of anxiety, typically due to a lack of clarity and plenty of situations without solutions. It seems to me that there is never enough guidance for psychiatrists in training. That situation is often made much worse by the fact that psychiatrists in most tertiary care centers are viewed as the physicians who take care of problems that do not neatly fit into other speciality areas. I thought I would post a few landmarks and tips that can lead to avoiding big problems and facilitate the transition to a practicing psychiatrist.
1. Boundaries, boundaries, and more boundaries...... - There is probably nothing more important in training and in the field than maintaining the appropriate boundaries of a professional. That means with your patients certainly but also with other professionals and medical staff, colleagues, and even people seemingly peripheral to the treatment process. There are many definitions of boundaries than invoke psychodynamic terms that are inaccessible to most. The most basic definition is that the psychiatrist is always aware of their special role in the treatment process and the fact that their behavior is dictated by a professional code that recognizes the physician must act in the interests of the patient. That certainly involves maintaining confidentiality but also subtleties such as determining why a certain patient evokes an emotional response or reaction that other patients do not. Most training programs discuss the issue of sexual involvement with patients and why that is absolutely forbidden. Boundary violations can be as subtle as being more available for one patient relative to the others and rationalizing this as the patient needing crisis intervention that only you can provide. To a certain extent residency is about picking up these subtleties, but in many cases it takes years of practice to recognize the most subtle boundary problems. Treating the family member of a friend or colleague is a case in point. Training staff should always be available for consultation on those issues. A good general rule is to always see the patient in a designated clinic at the appointed time, for the correct duration, and always document what occurred in the session using standard clinical documentation. Any unexpected thought or feeling on the part of the resident during the sessions should be considered for discussion with faculty supervisors. It is advantageous for faculty to describe what those scenarios might be in order to provide more active guidance. Many boundaries are more clearly delineated now than at any time in the past. For example, it was common practice in the past to be approached by somebody who was not your patient (usually a friend, relative or coworker) with a request for a prescribed medication. The usual rationale was it was more convenient to get it from you than their personal physician. Responding in many cases was problematic. Today it is quite easy to point out that most boards of medical practice take a negative view of prescribing to people where no physician-patient relationship and no documentation of an encounter exists.
2. Therapeutic neutrality - Figuring out why psychiatrists need to be neutral in their interactions with patients takes some doing. You may have just finished a rotation with a very demonstrative non-psychiatric physician and seen some interpersonal behaviors that you are not observing in your psychiatry staff. Asking them why they interact with people in a certain way and why they make specific comments to patients is an important part of the training. They should be able to explain themselves.
3. Pattern matching and other skills - The main advantage of physician training is the development of pattern recognition and pattern matching skills that covers a broad range of clinical experiences. The best way to differentiate between an acute pulmonary embolism, a myocardial infarction, and and a panic attack is to see every possible variation. That will make your chance of making the correct diagnosis much greater than a person who has read about it in a book. Some studies have looked at the number of recognizable patterns that can be detected by the human brain. For visual modalities alone that number approaches about 80,000 patterns.
4. Getting on top of the countertransference - During any training you will see a diverse number of clinicians with diverse theoretical backgrounds demonstrating their techniques. There may be some confusion about the benefits of therapeutic neutrality. Some people see it as being non-directive or even confusing to the patient. The equate neutrality with inaction. A much better way to look at it is that you will not interact with the patient at the emotional level that he or she expects. You will not interact with them in the same non-productive way that all of their friends and relatives have been interacting with them. Your goal is to complete your assessment or treatment intervention and demonstrate that they can interact in a productive way with you. I have seen some professionals get angry with patients and react emotionally and describe it to me as "reality therapy". I think that is reality insofar as the significant people in that person's life interact with them in the same way. I do not see that as providing much guidance on learning new and productive ways to interact.
5. Not getting rid of the stethoscope - Trainees are still responsible for a lot of medical work including admission histories and physicals, understanding the complex medical conditions encountered in tertiary care centers, and gathering and interpreting the medical tests and information necessary for acute psychiatric care. A big part of that is not missing an acute medical condition that needs immediate care or a medical condition that is causing the psychiatric symptoms. Some of that is learned in #3 above, but there is also an entirely different set of skills associated with medical diagnostics as it applies to psychiatry. At the minimum I would include Cardiology skills including the recognition of acute emergencies, common arrhythmias and how urgently they need to be assessed and treated, acute and ambulatory care of hypertension, and how to read electrocardiograms. All of that knowledge needs to be translated to patient care. The other areas include Neurology and the same recognition of emergencies, movement disorders especially tardive dyskinesia, but also drug induced problems. All psychiatrists should know when an electroencephalogram is useful and when to order MRI, CT, and PET imaging. I have been reading all of the imaging studies that I order throughout my career and with most electronic records systems - this seems like one of the functions that works well. As a resident you should find out where the Radiologists and Neuroradiologists hang out and ask them questions about images that seem confusing. Endocrinology and Renal Medicine knowledge has also served me well over the years. One of the most important aspects whether you are a resident or an attending is what you can learn from your colleagues. All of the consultants I have worked with have been very bright and highly motivated people. You acquire an unexpected amount of knowledge from them. To give one example, a Hematologist taught me a good way to treat sickle cell pain crises in patients with addiction to minimize their exposure to opioids. His method worked much better than the approach being used by a pain management clinic and stopped frequent admissions in inpatient units for pain crises.
6. Yes - you need to do talk therapy - I don't know how the myth started that you could be a psychiatrist and not talk to people in therapeutic ways. That is a completely unrealistic approach to the field. All of the superb psychiatrists I have known talk to their patients and have excellent skills whether that is in doing psychoanalysis or 10 or 15 minutes associated with a visit that is focused on a medication. Part of this myth seems to have originated on the inpatient side and the idea that you can't treat psychosis with psychotherapy. In fact, there are many situations in acute care where the patient may be refusing care or refusing medications and somebody needs to communicate with that person. Your life will be a lot easier as a psychiatrist if you are that person.
7. Study human consciousness - Even as a resident in the 1980s, the DSM technology had lost most of its luster when I realized that there were unrealistic categories and the application of diagnostic criteria could rarely be applied as easily as it seemed in the research. Over the years, it is even more obvious that people do not provide consistent histories over time. Some people will say that is a failing of the DSM, but it is clearly the real way that people think. You will certainly have to know the DSM and come up with DSM diagnoses in the foreseeable future, but do yourself a favor and focus at least some of your energy on how people really think. That includes knowing how human memory really works, being able to do a lot more cognitive screening than the Mini-Mental State Exam, and being able to immediately recognize the pattern of delirium from across the room. It includes knowing about complex decision making and the neurobiological substrate for those functions. It applies to how people typically think about whether or not they have any formal psychiatric diagnosis.
8. Neuroscience - This is the future of the field. There will be no demand for psychiatrists in the future who don't know brain science and how it can be applied diagnostically or therapeutically. It is the logical basis to study human consciousness, complex decision making and psychiatric disorders and contrary to what you might read on many blogs there has already been considerable progress in this area. There are many excellent psychiatrist-researchers in this area already and I encourage reading their research and some of their popular works as a starting point. There are any number of Luddites out there who seem to think that psychiatry needs to remain stagnated in the 1950s to provide any value. I don't think there is a shred of evidence to support that contention or that neuroscience will never be of value to psychiatrists. A good starting point would be to read Kandel's 1979 article on plasticity, his recent article on nicotine as as a gateway drug, and everything that he has written in between. If your department has a neuroscience section, asking them to compile a reading list of what they consider to be the top neuroscience papers that apply to the field would be an added bonus.
9. Don't be an overprescriber - When learning psychopharmacology it is tempting to consider patients to be constellations of biologically treatable syndromes. There are many problems with that approach. First and foremost is the inability to recognize the main problems in the context of a comprehensive formulation of the patient's temperament and personality. The other problems include not recognizing that a patient is unable to take a medication or tolerate it and the basic fact that in many if not most cases there is a psychosocial or psychotherapeutic approach that is on par with medications and it has fewer side effects. There are many other considerations for overprescribing and this diagram lists a few.
10. Keep yourself and everyone safe - Every resident is thrown into the breach with inadequate preparation for worst case scenarios. To prepare me, one of my attendings told me about his experience at the same hospital when he was a resident. He was called when a patient was discovered on the roof of the hospital and went sprinting up the stairway to intervene. He discovered a highly agitated patient in hospital clothing standing next to the edge of the roof. As he tried to calm him, the patient sprinted over and bit my attending on the bicep. It is hard to figure out how that breach of security could have resulted in a better outcome. The best way to be prepared is to learn to recognize warning signs and talk that over with the staff ahead of time. Work with the staff you have to come up with detailed plans to assure everyone's safety ahead of these incidents. In most training programs nobody ever discusses this problem.
11. Be a team player - On both the inpatient and outpatient side you can delude yourself into thinking that you are functioning independently and that you and your patients are in a separate parallel universe. Nothing could be further from the truth. Other staff talking about you and your behavior can have a profound effect on the kind of care that you can provide to your patients. It can also impact on your relationship with the patient directly and also on your personal safety. Think about your relationship with everyone in the treatment environment and how to keep interpersonal conflicts to the minimum. On the inpatient side, the relationships with nursing staff are critical. The worst possible scenario is a resident who develops a contentious relationship with nurses and views them as creating extra work for him or her. Part of any psychiatrists' role on the inpatient side is to make sure that no splitting occurs and that highly problematic dynamics involving staff and patients are avoided. It is good to keep in mind that the only reason patients are in a hospital setting is that they need 24 hour nursing care. They are not there to see a psychiatrist once or twice a day.
12. Know addiction inside and out - It is very tempting to take the same approach to addiction that some people take to medicine and that is: "I only practice psychiatry. This is my psychiatric diagnosis and you will have to get your addiction diagnosis and treatment plan from your addiction psychiatrist or addictionologist." This is less tenable than bailing out on medicine or psychotherapy. The reasons are fairly clear cut. Substance use disorders are major sources of differential diagnoses for primary psychiatric conditions. Substance use disorders also put people at greater risk for developing psychiatric disorders and in many cases the neurobiology of those changes is clear. Addiction and craving is also another unique conscious state with the opportunity to look at the neurobiology of complex decision making from another perspective. Most residents are also in training environments where they are responsible for the acute care and detoxification of patients with substance use problems. In many medical centers that responsibility falls to the psychiatry service.
13. See as many patients as you can see in a number of training settings - When you listen to some of the griping that happens as people complain about the number of admissions, the number of inappropriate admissions, conflicts with other medical and surgical services or just the overwhelming amount of work that accumulates it is easy to miss the big picture. The more patients you see, with more problems, the better doctor you will be in the future. At some point you will be out in practice and somebody will ask you to evaluate an acute disturbance in a patient and you will remember that immunocompromised patient you saw in a transplant unit as a resident. You may be the only one able to make that diagnosis - not based on what you read in a book but by being there as a resident.
14. Organize your study and reading around patient care and dig deep - It is easy to get lost analyzing a single case when you think about everything that involves. The pharmacology, drug interactions, drug-disease interactions, side effects, unique patient characteristics, phenomenology of the patient's symptoms and what that involves, what the patient is trying to communicate and how you can signal that you not only understand but you can suggest techniques to approach these problems are independent of medications. You are as comfortable quoting the latest treatment guidelines as the spectrum of medication side effects. A set approach to that process is useful. I typically start with Medline, add to existing collections I keep catalogued there, and read through my favorite journals. For the latest info on medical conditions I subscribe to UpToDate and keep up to date on the medical conditions that my patients have. I have a good 30 years of reference books in my library and information flagged in those books that I can't find anywhere else. My prized possession is a copy of Encephalitis Lethargica by Constantin Von Economo. That interest was based on my exposure to surviving patients with complex neuropsychiatric and movement disorders while I was still a medical student.
15. Recognize that there a lot of people out here who hate psychiatrists and that is not your problem - Any casual read through this blog illustrates the problem. The haters are deep, in multiple settings, and paying attention to them can be draining. One of the reasons this blog exists is to point out their fallacious arguments and to point out that you can do very well by not paying any attention to them. In some cases departments of psychiatry have been fooled into bringing in some of these people to give Grand Rounds as though it is a legitimate academic exercise. That is typically a mistake and it seems so unreasonable to me that I would conclude that people in that department are either incapable of critiquing them or have just run out of things to say and need speakers. Engaging most of these people is a waste of time. They have a number of fallacious arguments and the most telling factors include the fact that psychiatrists readily critique the field and do a better job. Many of the arguments provided by these groups have an obvious lack of scholarship and in some cases are over the top.
16. Recognize that conflicts of interest are everywhere - Pharmaceutical company pizza has vanished but it is no worse to me than a blogger claiming that he or she knows what is best for all psychiatrists. The critical part of residency training is to learn to critique research that impacts your patient care. I agree with Ioannidis(1) observation that almost all published research is false. I base that on my reading of medical and psychiatric research for the past 30 years. That does not mean that you don't have to know that research and how to possibly apply it. There are also critical delineations in the research literature between basic science and clinical research that nobody seems to talk about. Practically all of the focus is on imperfect clinical trials, frequently with the implication that somebody is doing something wrong. Know the difference between the appearance of conflict of interest and conflict of interest. Reviews and meta-analyses by researchers with clear agendas who are reanalyzing collections of studies are not the same as large clinical trials and generating research findings. Some of the sites that promote the review methodology do not provide much useful information for clinicians. At some point in your career you will be treating many more cases than are published in the largest clinical trials so pay attention to what you are doing. Finally know the political implications of conflict of interest including the new laws about how physicians are reported for the appearance of conflict of interest and the implications that may have for your transition into psychiatric practice. Get the opinions of your training staff on those issues.
These are a few anchor points that come to mind as I sit here typing on a Friday night. I hope that they are useful to residents. Sometimes the most basic idea takes on a great deal of importance. That is especially true when you are in a hospital at night by yourself and trying to keep the place together until sunrise. There are very few people who know what it is like to be up all night trying to figure out solutions to problems where no clear solutions exist. Make sure that you don't isolate yourself when faculty backup is available.
I can remember seeing the sun come up after many of those nights and the tremendous feeling of relief that I had made it through another night of call.
These are some of my ideas. I would appreciate the opinion of any other training staff about gems that they found most helpful in making the transition to practicing psychiatrists and avoiding land mines along the way.
George Dawson, MD, DFAPA
1: Ioannidis JPA (2005) Why Most Published Research Findings Are False. PLoS Med 2(8): e124. doi:10.1371/journal.pmed.0020124
1. Additional points on Advice To Residents can be found here.