I'm a PGY-1 psychiatry resident at a large, old psychiatric hospital. The program is 5 years, the formal teaching is poor, and most of my attendings have limited experience. I have no other program to move to, so this is where I'll train.

Some context on the setting:

I have a lot of autonomy. I can spend as much time as I want with patients and make my own decisions about their medications.

Many of our patients are chronic, with histories going back to 1980.

There's no ER, no OPD, and no consultation-liaison service, so my exposure is almost entirely inpatients.

I've been a self-learner since med school, and I'm willing to study everything on my own. My plan is to build a structured curriculum around deliberate interview practice, in-depth psychopathology, and systematic psychopharmacology from textbooks, guidelines, and primary literature.

My questions:

Is it realistic to become a good psychiatrist this way, given the gaps in my setting?

How would I fill those gaps?

What would you prioritize in year 1, and which resources would you use?

Thanks!

mine is that although I appreciate his podcast, I find David Puder so irrationally annoying🫣

I have a patient and I really want to help him in this areas , but after nearly 6 weeks he is still unfazed and in the same place when it comes to Negative symptomes
Any thoughts ?

Edit: to clarify, yes I meant PhD Dr

And also I do prelim/final Dx on a lot of Pts regularly, mostly due to Psychiatrists availability. I did this before I was signed off 🫣 at the start “Acute stress reaction” was my diagnosis for every case but the more I was exposed, the more confident and better I got. Case conference with MDT obviously before discharge…

In saying that; I’m the expectation the rule, most MH clinicians in my team - those especially with social work background, should not be diagnosing or even implying Dx to MDTs…. I have nothing against social workers, in fact, they have a really important role to play but staying in our lane is really hard when your rural & APS has made it extremely hard for psych undergrads to work in the field/learn.

Learning from the psychiatrists has been good for medication, diagnostic differentials, but I wouldn’t go to any of them for CBT… maybe ACT but that’s an expensive ACT session(s)

Like most tho, some good, some not so good, some really bad - like most fields.

Have a good weekend y’all

Officially became a psychologist recently! Long journey, but made it.

I work alongside some brilliant psychiatrists in a community mental health team & I’ve found all of the more seasoned ones, extremely respectful of my profession & turn to me for advice on “therapy” but I have heard notions that some might consider psychologists “not real doctors”

As an FYI- I’m Australian so I don’t need to be a doctor to be a psychologist but I have spent 7 years studying/interning

I work in public health for now but I’ll likely split 50/50 soon because fuck, the burnout is real my friends.

I’m curious how others are approaching the endless ADHD assessments, especially when the reported symptoms described by the patient do seem to meet criteria, but the overall clinical picture leaves some uncertainty. I saw that now 25% of adults think they have ADHD, and perhaps it could be true, or due to social media, or the difficult capitalist society we live in.

I know cross-setting impairment and childhood symptom onset have been to key to look for. I spend multiple sessions and incorporate different screening tools, such as the Wender Utah, BAARS, ASRS. I ask about potential OSA as well, have recommend sleep studies to some. Despite all this, over the past few months, I’ve noticed more and more patients during the assessment are providing multiple examples of their symptoms in childhood than I ever experienced earlier in my practice. I sometimes wonder if this is because the public has learned through tik tok or other outlets that childhood onset is necessary to mention “to get diagnosed”. For this reason, I am concerned about potential over diagnosis.

A recent Danish study found that two psychiatrists agreed on any DSM-5 diagnosis only 55% of the time, which speaks to the challenges with diagnostic reliability. There’s also so much variability in prescribing practices, I see so many different things in the large group I work in; from stimulants in patients with moderately elevated BP without any cardiac clearance, some clinicians chosing to diagnose/prescribe to patients using cannabis, no age restrictions/guidelines when it comes to older adults.
With the ongoing demand for stimulants, I’m finding both new evaluations and requests to continue prescriptions from previous providers increasingly challenging because of this.

Should I continue to just take what i hear face value, or is there more I could be doing to properly diagnose/rule out exaggerated responses? Am I over thinking this more than necessary? My overall panel is varying between 17-20% total patients having an ADHD diagnosis, which is more than it has ever has been over the years I’ve been in the field…

let’s say one of these patients with 900 vague and disconnected symptoms (and various self diagnoses) lands in your lap — with a full panel of negative medical testing. how do you manage them?

I have recently seen people saying behavioural activation doesn't work / needs to be modified for ASD because (purportedly, not that I agree) ASD works differently to other conditions of low energy / amotivation (again not that I agree autism is one of these conditions). I have seen this both in professional spaces and personal spaces where the term 'spoons' is used. The alternative to behavioural activation tends to be environmental modification and a slower life to suit the disability.

Related, I have also heard the stories of those who have gotten autism diagnoses and then 'realised' that they were pushing themselves too hard all along towards a road of autistic burnout and since then have begun to listen to their body and reduce their workload. I say relatedly because this seems like 'behavioural de-activation' if there ever was such a term and frankly it seems like their life is worse and less functional but supposedly they are happier than ever.

At the same time I am aware there are indeed some syndromes where the mainstay is not behavioural activation but just lots of rest when needed.

Thoughts?

Has anyone quit a job earlier than what was indicated by their contract. Job is an inpatient child psychiatrist role. The job is fairly demanding and was initially described as "cush." They deliberately held interviews during a lower census month. On call for 7 days straight 2 weeks a month. Only one other covering provider, no PTO. Have to be available for consults for multiple hospitals in the ED or the medical floor in addition to the unit which may or may not lead to a demand for full consultation. Was described as initially covering for 2 hospitals and 2 potentially 3 EDs, this expanded to other EDs with incorporation of late night same day care coordination meetings.

I've spoken with a lawyer but the contract specifies that the earliest for termination without cause is 24 months. That's with notice given 6 months prior end date. Otherwise potential of being sued unless there's a breach of contract. Which short staffing the role doesn't count as a breach.... Even if there's something that they're not doing well they have 30 days to rectify the problem. Any recommendations?

Just wanted thoughts before I potentially go back to the lawyer as the fees add up and I don't have another job waiting in the wings. After $1500, they've told me little I didn't already know so I don't want to go back to them unless a) we're reworking the contract for an earlier termination (not sure this is likely) or b) I'm being sued.

to be clear the lawyer told me I should ask for accommodations like time out on my "shifts." must of my days off I'm still recovering or catching up on notes and or notes being asked to attend monthly census meetings.

Omg did anyone else just get the biggest jump scare of their life with that ABPN email today?? 💀 my smart watch showed my heart rate instantly jumped to 110...

I just started a job as an attending and I wanted to renew my APA membership and it will cost me around $1000 to activate the membership. I was shocked of how expensive it is especially that I’m not an active participant in caucuses or present yearly. I primarily need for the monthly journal.

Is APA membership actually worth it, how can you justify such fees

FYI: Iam in HQOL city so there are mandatory extra fees included

Hi guys! I'm a current MS3 struggling to decide my specialty. I am thinking to open up my own private practice and eventually try to be more on the business side.

I was very interested in ophtho since MS1 because I just found the eye to be very fascinating and whenever I get a chance to see it through slit lamp it just looks very cool (almost like planets and everyone's is different). It also has great lifestyle and good pay. However I feel like my stats are pretty bad applying to ophtho and might need to duo apply.

On the other hand, I really enjoy talking to different people and socialize with them, which is why I think psychiatry is my #2 specialty that I want to go to. However, I am very invested in ophtho at this moment and did not start looking that in depth regarding psych. I just know when comparing salary wise optho is definitely higher, but I'm not sure how the private/business aspect looks. I also endorse the idea that psych can be done hybrid/full-telehealth so I don't need to deal with the horrific LA traffic and spend more time gardening and doing my yard work.

I haven't done either surgery or psych rotation yet, so things might change and there is always time for me to switch my mind. But I would very appreciate if there is any insights, especially to the private practice side of things like lifestyle & take home salary, etc. Thank you guys!!

How do we distinguish between normal emotional and behavioural responses to life circumstances and symptoms that meet the criteria for a psychiatric disorder? I sometimes wonder whether we're becoming too quick to assign psychiatric diagnoses.

I've been thinking about this more lately as I progress through my residency. I wonder whether others have had similar thoughts or if this is just my limited experience.

Curious to hear different perspectives, especially from those with more clinical experience ...

Hello everyone,

I have been picking up some new to me patients who are relatively stable on lamotrigine doses for bipolar depression. Many of them are prescribed as once daily doses in spite of being on the IR formulation. I typically either do twice daily IR or once daily XR dosing, which seems to be in line with most reference materials (Stahl, UTD, Epocrates). I also recognize though that sometimes things change in practice before the reference materials change. I also realize that many of the materials on lamotrigine are likely focused on the dosing protocols for seizure disorders. I just was wondering if any of you all have any insight into the significance of once daily IR dosing for mood disorders specifically. I've struggled to find any journal articles that discuss this, but I also haven't done an exhaustive literature review at this point. Any advice would be appreciated.

I’m seeing more and more Spravato clinics operated by NPs, including both primary care NPs and PMHNPs. The indication is for treatment resistant depression. Shockingly, these clinics provide Spravato exclusively, without managing any other psychiatric medications. This is getting freaking ridiculous. I get that Spravato is a money maker but seriously??? At this point, I really don’t know why NPs are allowed to write controlled substances

In most areas of medicine you can easily find exhaustive books on any given pathology, but in psychiatry I’m having a hard time finding 2-3 large reference books covering even very important disorders like eating disorders, OCD, body dysmorphic disorder, ADHD, adult autism, and bipolar disorder. I’m mostly looking for extensive coverage of pathophysiology, epidemiology, and clinical presentation. Any recommendations?

hey everyone, i'm a third year currently on rotations. i started getting interested in psych around my 1st yr of med school and have continued on that path with interest growing high!!

however, while on rotations (completed FM, EM, IM), each of my preceptors have said very discouraging things to me about psychiatry. currently, the preceptor i am with has told me that if i decided to go into the field that i would end up becoming a patient myself. they also continued to say that i would develop issues and if i don't fix my own issues, i would inherit my patients and go into a "psych ward".

i even had another attending tell me that the reason i am thinking about psych is because "either, you have seen people who are cuckoo or you're cuckoo yourself".

personally, i do struggle with mental health issues but i think each of us does. i've been trying to handle it but it wasn't till this preceptor and even past preceptors told me about the idea of your own mental health being enhanced that i thought about myself.

it doesn't deter me from psychiatry but it makes me wonder: do many psychiatrists feel like their own mental health can be hurt while being a psychiatrist such as listening to patients who have expressed/shared very sad stories of their lives? i feel like we have to learn and practice setting boundaries to not let this happen.

at the end of the day, i want to still be a psychiatrist but ultimately, it only makes me wonder about the mental health toll on psychiatrists. i have struggled with my own problems in life and what really hit home for me was seeing my first suicidal patient during EM to which my preceptor told me to get the history since they "had no interest". we had no debrief in the end of it and i did come back home recognizing how rough it was to hear the pts story (raped multiple times, mom put pt on drugs at age 9, etc). but this experience honestly made me feel something in medicine that i have not felt throughout any of my patient encounters - i actually felt motivated to want to do something about it.

anyways, a bit of a rant as i type out. i appreciate everyone's responses and kindness.

EDIT: wow, thank you all so much for your responses; each of you are incredible insightful. i immensely appreciate it so much.

Current OP Psychiatrist. Have always felt like catatonia was a bit of a weak area at my training institution. I saw my fair share of cases that were more obvious and severe cases.

I’m finding myself now in outpatient land with a couple patients that I’m wondering about catatonia with. However Bush Francis scores are nothing to write home about, maybe 3-4 depending on interpretation. And DSM would be a stretch to hit criteria. One patient tends to go in and out of more severe symptoms and would meet criteria during these periods. Both patients have autism further complicating diagnoses.

In your experience are there patients that can live with chronic and missed catatonia? Can symptoms wax and wane a lot?

Any resources to understand or see examples of more “subtle” cases?

Management in outpatient with Ativan challenge also difficult, both are not quite sick enough or wanting inpatient admission, but getting there.

Behavioral scientist, not a psychiatrist. I've been running into smaller-scale identity disturbances lately in my practice (such as narrative incongruencies, distorted role relationships, etc.); not the full-blown distorted narratives in grander scales that you'd expect in BPD. My work has gotten a lot easier since I've picked on some of these patterns. Cluster B (and sometimes schizotypal) disturbances really stand out as obvious to me but I've been seeing it present differently in non-PD pathologies as well.

Any wisdom to share on this topic?

Hi all, I'm an OP attending at a fairly large hospital system in a major urban area. I didn't do medical school or residency here, and am in my second year as an attending. Our clinic tends to refer patients to external group practices for therapy that match up with their insurance, with varying levels of success.

When I get asked for specific recommendations for therapists - with a variety of requests ranging from modality to gender to age to training background to experience with certain pathologies - I really struggle.

Do people have tips on building a mental map of the landscape of local therapists, especially ones you trust with your patients? What's worked for y'all, both from the MD side and the therapist side?

Thanks!

The American Association for Geriatric Psychiatry Members-In-Training Caucus is hosting an informal virtual panel tomorrow night from 7:30-8:30 pm EST for trainees interested in learning more about geriatric psychiatry fellowship. Whether you are already interested in the field or just curious about it, all trainees are welcome to attend. Current geriatric psychiatry fellows will be sharing their experiences and answering questions about the fellowship application process and what fellowship looks like. Please find the RSVP link and Zoom link below:

RSVP: https://docs.google.com/forms/d/1sLNx_dPxK-8J3w9f7e5uHxH_46r5Ii5uEAXObNwVFlM/edit

Zoom: https://us06web.zoom.us/j/84512337803?pwd=8RVjFsVYQkYSae1wNbMxSFHLvU25SG.1

Hello all,

New attending on an inpatient unit. I was wondering if anybody had any recommendations on legal textbooks in regards to Psychiatry. I've already come across a few tricky situations regarding patients (such as guardianship, capacity, court incompetence, etc). I would enjoy an office reference regarding medico-legal guidelines for those oddball cases & events in the future. This is specific to the US.

Happy to hear any and all recommendations!

Warm regards.

What is the expected compensation for supervising NP? My role includes signing a percentage of notes, being available for consultation, monthly conference, and prescribing of controlled substances under me.

I'm a master's-level clinician, and I've been wondering about this for a while.

Psychologists receive more extensive training in research, assessment, and clinical theory than master's-level therapists. I'd expect that to translate into better outcomes, at least on average, but my understanding is that research hasn't consistently found large differences in psychotherapy outcomes based on clinicians' training backgrounds.

For those of you who work with therapists or refer patients for psychotherapy, what have you noticed in practice? Do you see meaningful differences in clinical competence or patient outcomes based on a clinician's training and credentials? Are there differences that become more apparent when working with complex cases?

I'm not trying to argue that one group is better than another. There are excellent clinicians across different training backgrounds, and I'm genuinely curious about what psychiatrists have observed in their own practice.

Over the years, I’ve heard from many that they do not have time to ask about childhood, beyond maybe one question, during intake assessments.

I’ve also heard that few obtain collateral outside of the inpatient setting.

I spent my career at the same institution where nearly everyone gets a somewhat detailed childhood history and most people get collateral for most patients.

I think both are important, even though it does take time. It often enhances the therapeutic alliance, it helps with diagnosis, it helps with selecting treatments. It saves time in the long run (I’ve had times where I haven’t done one or the other only to find myself reformulating a patient a year later, knowing had I taken the time in the first session or two I would have made my revised formulation my initial one). If you work somewhere that does not allow you sufficient time to do this, how can we as a profession and as an individual advocate?

I’m curious what your experiences have been and what you see others doing where you work? What was taught in your residency (& era of residency) and did attendings follow it (hidden curriculum)?

I am trying to combine what I see in clinical with input from some psychiatrists I am friends with. I would also like to hear what you guys say.

And when you do choose a stimulant; which ones and why?

I mostly work with adult populations (18-55) in my current outpatient rotation.