Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third year student.
Throughout my third year, I have encountered hundreds of patients, many of whom I’ve had the privilege of working closely with, some for many days. Although I’ve met many important people who have taught me much, by far the most meaningful and interesting patient encounters I’ve had were on my Psychiatry rotation. This rotation was unique in that it allowed and encouraged more time to speak with patients. Although this is central to psychiatry – it takes a long time to do a thorough patient interview and mental status examination, especially if the patient’s story is complex – the byproduct is that it allows students extra time to practice interviewing patients. Most of the patients I worked with during my six weeks were very willing to talk with me, and I am extremely grateful to them for allowing me to hear their stories and learn from them. This is a theme of medical school, particularly this year, about which I plan to say more in a future post.Psychiatry is the medical specialty that focuses on the treatment of the mentally ill. This is not to be confused with psychology (though many do confuse them) which shares common themes but requires a very different approach and career path. The psychiatrist is a medical doctor who specializes in the treatment of mental disorders such as schizophrenia, bipolar disorder, anxiety, depression, and drug use, including addiction, intoxication and withdrawal. Psychiatrists work in a field that continues to grow; recent awareness of and support for mental illness research and treatment has been largely led by psychiatrists. Despite being one of the oldest medical specialties, it continues to be at the forefront of research and advancement; many of the disease processes are more understood than they once were, but are still largely a mystery.
By its nature, psychiatry is a narrow slice of medicine, but it has incredible depth that resists easy mastery. The advent of diagnostic criteria, most notably the DSM, has helped provide structure and bring order to an otherwise chaotic system of evaluating patients and providing diagnoses. Even so, the field often boils down to the uniqueness of each person and the infinitely varied states of the human mind. My rotation was long enough to learn the basics of diagnostic criteria and common treatment plans for a variety of disorders, but because each patient is unique, I am still very much a novice at figuring out the subtleties involved in the process. Two patients with similar characteristics at a glance may in fact have completely different etiologies of their symptoms, and discovering the background and deciding how to treat can often be incredibly complex. This opportunity – to elicit subtleties both in diagnosis and therapy – makes it a compelling field for problem solvers and creatively-minded medical students. Psychiatry requires a high degree of clinical judgment, and the endless combinations of comorbid conditions and individual personalities necessitate a physician who is ready for anything.
Of all the medical specialties, psychiatry may be the most different from other areas of medicine. Psychiatrists often work with patients whom other doctors are not willing – or trained – to treat, given the fundamentally different nature of the symptoms and disease processes. Standard ideas about pathophysiology and treatment modalities which are common to other areas of medicine are simply not practical to much of psychiatry. One of my preceptors drew attention to this by saying, “I wish I could just draw blood and say yes, you have bipolar disorder, but it doesn’t work that way.” When the illness is a mental one, the approach must be tailored to the problem, and this requires both a strong understanding of the human mind and the patience to thoroughly investigate a story, often from multiple angles.
Psychiatry is essentially non-procedural, relying heavily on the patient interview to make a diagnosis and treatment plan. Even so, psychiatry involves more than meets the eye. Most people will imagine a psychiatrist in an office with a couch, asking “and how does that make you feel?” While there is truth to this caricature, as a discipline there is a wide range of activities and options. Outpatient psychiatrists may work in a private office or clinic, and may engage in psychotherapy or see mostly patients who need medications managed. Psychiatrists may also work on an inpatient unit and provide care to those patients sick enough to require hospitalization. This can range from a small ward at a community hospital to a state-funded mental health hospital. A lesser-known area of psychiatry is consult-liaison, which allows the psychiatrist to interact more closely with other specialties. These physicians must be particularly knowledgeable about non-psychiatric areas of medicine, since they often evaluate patients from a variety of specialties. CL psychiatrists often do maintain physical exam skills, integrating medical knowledge into psychiatric patients and vice versa, and working to solve mysteries that might stump other specialists.
One of the most striking components of the clerkship for me was the major effect psychiatrists had on their patient’s’ lives. Although it isn’t a specialty often associated with critical care or “saving lives,” many are suited to save the lives of patients. This is particularly true for schizophrenics, who are rejected and/or feared by most of society. Yet these people often improve – not cured perhaps, but brought to a safe level of functioning – by the right medications. Without it, they might freeze to death or commit suicide. Patients struggling with depression can also see major improvement when put on the right medications and given time to talk with a trained therapist; this tangible improvement in a patient’s mood can be incredibly rewarding for psychiatrists.
Throughout medicine, the major shortage of mental health professionals and the correlative need for more is a very common theme. This has been mentioned to me by everyone from nurses to trauma surgeons to psychiatrists themselves. While this is unfortunate for society, it does create a value to the field for students interested, because they can make a major impact immediately upon graduating while enjoying job security. Even so, it takes a particular type of person to do psychiatry and do it well; the difficult aspects include patients who do not want to receive treatment, legal and ethical issues, dealing with insufficient funding and resources, and of course, managing diseases that may not ever be cured. But there are opportunities in psychiatry that are rare in other parts of medicine – continuity of care, the opportunity to provide integrated care through collaboration with social workers and psychologists, the lifestyle including pay, and a variety of career options. Psychiatry is often paired with administration, teaching, speaking and writing, both because of the mutual impact and because it allows the physician to balance his/her time in a way that others traditionally do not.
Psychiatry is a four-year residency program, or three years upon completion of a general inpatient year. This is a common question for students – why does psychiatry, a narrow slice of medical care, necessitate a year more than (for example) family medicine, which must cover the full breadth and depth of medicine? The answer is the nature of the work: psychiatrists simply cannot provide good care if sleep-deprived, and there are parts of the field that must be learned over time, without cramming. Psychotherapy, for example, requires longitudinal experience, and cannot be done well by a tired, out of focus resident. This is not to say other fields excel when tired, but the adrenaline of the operating room or a busy clinic does make it easier. Thus psychiatry is longer to allow residents to obtain a depth not often reached. There are also subspecialty options, with fellowships in Addiction, Brain Injury, Child/Adolescent, Forensic, Geriatric, Pain Medicine, Psychopharmacology, and Psychosomatic Medicine. Many of these are offered as integrated programs, and they are additional combined programs that pair psychiatry with another discipline (e.g., Family/Psych).
This rotation was one of the most challenging for me, but also highly rewarding. The opportunity to work with patients with mental illness was extremely valuable to me, and I felt encouraged and supported by the attendings and residents as well. Keep an eye out for my March column post to hear about my next rotation in Family Medicine!
Brent Schnipke, MD is a physician and writer based in Dayton, OH. He graduated medical school in 2018 and completed his psychiatry residency at Wright State University Boonshoft School of Medicine. He currently practices in Dayton, OH. His professional interests include medical humanities, mental health, and medical education.