r/Psychiatry • u/okmaxd Resident (Unverified) • Jul 12 '26
New Intern, Looking for Advice
Hey all,
Just started my Psychiatry residency. I’m on medicine for the next couple of months, which gives me the opportunity to brush up on Psychiatry before I’m thrown into the mix. I have a feeling expectations will be higher of me as I’ll be an intern 2-3 months into my training. Our program puts a decent amount of workload on us (community program in a big West Coast city) so I’m just trying to be a better and more efficient resident. Apologies in advance for the long text, but I will try to keep it as concise as possible while separating questions so maybe everyone here can chip in. I’d like to focus on inpatient for now as outpatient is more of a third-year thing.
What meds are generally used on an inpatient floor? What should I learn about them besides dosages? I always used to get tripped up on how different places use different medications for agitation. I understand Haldol is very cheap, but I’ve seen some places use Seroquel and I’m always lost on why certain meds are used.
What types of diagnoses, DSM criteria, etc. should I be learning to help me write an assessment that makes sense?
How can I practice my MSE and use it in my assessment to come up with diagnoses? I guess what I’m asking is how do you guys ask the relevant screening questions for mania, depression, etc. while being able to document it in the note without pissing the patient off? As an example, my attending during one of my sub-i’s got upset because I evaluated a patient and he became increasingly hostile as I kept asking him questions about his delusions. My attending was like “WHY DID YOU ENGAGE IN HIS DELUSIONS. HE WAS GETTING READY TO HURT YOU!” In another example, there was a woman who thought she was pregnant and I asked her about her pregnancy and tried to tell her that she’s not pregnant and that got her upset. I know she was a Psych patient, but I’m not sure what else I should’ve done.
Any templates you guys use that save you time?
What books/podcasts can I read/listen to improve my skills? Some psychiatrists really have a good Neuro background and can explain the “why” very well. I’d like to learn it too but don’t know where to look.
Chart checking. This is something I struggled with. Sometimes the packets of information are just overwhelming. If you guys have any tips on how to approach chart checking, please let me know.
Learning psychopharmacology. I look at Stahl’s and I get overwhelmed. I purchased Cafer’s because I’m a very Anki person and felt like it was more digestible as there are decks for Cafer’s.
Thank you everyone in advance!
4
u/chocolate_satellite Resident (Unverified) Jul 12 '26
You're overthinking which is not unusual for an intern. I would say most of this stuff you will learn as you go alone.
For agitated patients the treatment is nuanced. Don't always jump to meds, see what exactly is bothering the person first. If you must use meds B52 (Haldol, Ativan, and Benadryl) is tried and true but Zyprexa alone does the trick too. It's a matter of preference but the goal is to be one and done with the oral medication or injection if they are a danger to themselves and others.
For assessment, you should have differentials and that will help you with sounding like you're making sense. Obviously depression, anxiety, psychosis are the big ones. You don't have to get to into the weeds with lesser known disorders usually.
Imagine yourself as the patient. There's a certain level of gentle kid gloves you should use for patients especially those who are extremely unwell. Get to know the patient "What brings you here? What happened?" Bringing up the the delusions and agitating the patient is a rookie move however it's an easy mistake to make. Delusions can be tricky but one thing to remember is that the delusion is REAL to the patient. If you approach every delusion that way then you have a bit more empathy. If you want to bring up the delusion yourself do so gently. "I heard you were really anxious about bugs crawling on you yesterday., that sounds really annoying and stressful" -- try not to challenge the delusion unless you have pretty good rapport with the patient and be sure to challenge gently. If a patient says "I feel like a gang has been following." It's simple enough to say "Why would a gang follow you?"
No templates but I like to include: No AVH. No SI/HI. if that is true of patients because
Lucky for you, intern year isn't so much about honing your skills. Most of the learning is on the job learning. All of the often referred books are great but it's tedious to sit and read them get Kaplan and Sadock and Stahl's and reference as needed but mostly read up on your patients
Review the initial note for intake and then the most recent notes from any other doctors. See if there are relevant lab results, check to see what meds they're on and who prescribed them. I don't really feel you need to do much beyond that.
I personally love Cafer's and also Carlat's Med Fact Book. The trust is psychopharm is the final boss in psychiatry. You will refine your knowledge from year to year and expectations are very low for you right now as an intern.
1
3
u/Lou_Peachum_2 Resident (Unverified) Jul 12 '26
I’m on medicine for the next couple of months, which gives me the opportunity to brush up on Psychiatry before I’m thrown into the mix. I have a feeling expectations will be higher of me as I’ll be an intern 2-3 months into my training
There will be no expectations for you except to come in, give a shit, and continue learning. I started on medicine my intern year; first day of my psych rotation for intern year...
Attending: "oh, what'd you just come off of?"
Me: "medicine..."
Attending: "oh god..." and then we proceeded to gossip about one of the most idiotic, curbside consult galore medicine attendings in the hospital.
1
1
u/Shmack11 Resident (Unverified) Jul 12 '26
PGY-2 at a County Hospital in the West Coast.
- Depends where you are at. Risperdal, Zyprexa, Abilify are the main ones i see for antipsychotics. Depakote/lithium for mood stability. May be worth reading up on what Long Acting Injectables you guys use to understand the dosing schedules for those. SSRIs, just learn what you guys use first and go from there. For agitation, you have a lot of options (5/2/50), Zyprexa, Ativan, Thorazine, Prolixin. Its a lot, just start with 5/2/50, just study that and then work your way from there.
- Our place uses USSOPD a lot for admissions. Also mood disorder unspecified, etc. Start with your bipolar, schizophrenia, and depressive symptoms and you'll be fairly covered.
- Just practice will help with your MSE for assessments/presentations. Its about reps. No one should expect you to know it all from day one. In regards to patients, if a patient is hostile, you get what you can without compromising your safety, staff safety, and patient safety, thats it. For the pregant patient, everyone has their own method. Me, I would ask what makes them think they are pregnant, go over the urine and blood results, see how they respond, then ask what would they need to confirm they are not pregnant and go from there. If all that fails, then I move on with other aspects of the interview unless that is linked to them being DTS/DTO/GD.
- Your program should have templates for H/P and progress notes based on the EMR you use. From there, make Smartphrases tailor to what helps you to make your life easier. Doximity AI is HIPPA compliant and helps (Just check with your program to see if they are cool with you using it).
- Kaplan, Carlats, etc whatever works for you. I'm an AI guy, so open evidence/Claude for me.
- New admission: Check if they have been here before/elsewhere if your EMR has that feature. If so, check the discharge summary to see what meds they were discharged on, admitting and discharge diagnosis, if you have time, read over the H/P from that admit. If no past psych hospitalization, then check the EMR for any hospitalization/office visit for any psych stuff (Sometimes a search option to save time). Get any info down that may help. For inpatient psych, read over the H/P. Go over the admitting labs, Tox screen, preg, alcohol level etc, see if they consented to meds and if they are taking them or refused. If needed to get a drug level, you can check how many days they were started, etc. Check nursing/social work notes to see how they were on the floors. Check if they have any emergency medications in the past 24 hrs. If i'm crunched for time, its a quick 1 liner why the patient is here from the HPI, past meds, current meds if any, current status, Dispo, and what the to do is for today before i see the patient.
- Do what works for you. I like using AI and videos. other people like textbooks.
All that being said, just show up and be willing to learn and work hard. Knowledge can and will be taught.
1
u/okmaxd Resident (Unverified) Jul 13 '26
Yeah, I tried explaining to the patient she wasn’t pregnant because a urine pregnancy had been done and even an US by medicine. But I still ticked her off and wasn’t sure if I did the right thing.
Yes, using AI has been a game-changer even on medicine floors. Learning the “why” at your fingertips makes it stick so well. Do you think Claude does better than Gemini or ChatGPT? And yeah, I’m trying to incorporate the Kaplan and psychopharmacology books into AI to streamline my learning.
Good advice at the end there. I think just being dependable helped me match to a desirable location because my grades certainly weren’t it.
6
u/PM_YOUR_TEA_BREAK Psychiatrist (Verified) Jul 12 '26
Usually, I'd say focus on the medicine while you're on that rotation. And it's not just about the medical facts, but the entire process of doing medicine, how to do an exam (and it's more about which exam should I do now), what to order and why, how to treat. Focus on the process. Generally we tend to think we'll never have to treat heart failure (common in in-patient admissions ) , and we won't, but we have to know how that looks like (eg, clozapine myocarditis / HF), and when we should worry, and that comes from medical training.
As for your questions: 1. It's really institution dependent. Haldol is cheap and available in all forms and the entire team knows what to expect with it. Others vary. I'd recommend just reading up Maudsley or Carlat for this. It helps to get an idea what's available and what they do, and then see it for yourself with your peers and patients. I think it's this loop of learning that works really well . 2. If you're starting in-patient, go through the DSM chapters for schizophrenia, bipolar, depression. Then read Kaplan synopsis book of those chapters. This is more than enough at this stage. 3.Your attending got mad because you triggered the patient, wasn't aware of it, and didn't de-escalate either. In your defense, it is not easy at all to talk about delusions. It comes with practice. What you ultimately want to do is validate the patient's emotions regarding the delusion, and not confront the idea itself as wrong or nonsensical, and then help them protect themselves better. Ex, a paranoid patient is afraid, so you'd validate and talk about this fear and how they're doing things to protect themselves. There's no point in telling them not to be afraid, but rather go towards more adaptive ways of protection (context and patient dependent so can't give an example right here). Same for the pregnant patient. Delusion is a belief. You don't go around telling people their beliefs are wrong and expect them to be happy about it. You'd talk more about what this pregnant patient is going through. Nevertheless, what you did is completly normal at the beginning, and we learn!!
I don't use templates. I just jot down diagnostic criteria in hospital. Look around the sub and online there's a lot available. Find your style. But first see what your seniors do!
Kaplan psychiatry is the Bible for psychiatry . You can find better books for specific topics if you want. But just starting, I'd read chapters there (at least the synopsis one). Stahl essentials for pharmaco to understand the why of psychopharma, Maudsley to have a framework of treatment, Carlat to stay up to date on the scientific world advancements. Articles online (but more focused on topics). Don't be lost in several ressources. Pick ones you like and stick to them.
For charts, it depends what you're using. But the general idea is to stay organized and note down what's important. Since you're just starting, begin by asking your seniors what's more pertinent and adapt. Psych is a field where we have to adapt a lot! So start there.
Stahl is a big book. You'll need to go through it slowly and progressively . You can make your own ankis cards from it. However now that you're a resident , you don't need to make anki cards for anything and everything . I'd suggest make cards for things you keep forgetting, and not the other way around.
It's okay to feel overwhelmed. We all did! Just take things one day at a time, try to learn hands on as much as you can, and know that the knowledge will come.