After completing my family medicine rotation, I moved onto my psychiatry rotation. I had no clue what to expect. Obviously, the patients are unstable. Maybe crazy. Possibly dangerous. I admit — I felt anxious but also excited.
My Experience with Psychiatry Rotation
I spent 4 weeks in the psychiatric ward at a small community hospital (the same hospital as my surgery rotation). The ward is split between two sides: the open side and the close side.
The patients in the open side are there voluntarily. If they want to leave, all they have to do is tell the doctor. Most likely, the doctor would allow the patient to leave. An exception can be made if the patient poses a danger to herself, others, or property. Most of the patients in this side are drug abusers, bipolar (without hallucination or psychosis), or depressed. If you met them on the street, you would probably think these patients are normal.
Those in the closed side are there involuntarily. They cannot leave, even if they wanted to. The patients would, most likely, be transferred to a different hospital — one that is suited for long-term psychiatric care. If a patient has shown vast improvement where she is not longer a danger to herself, others, or property, the doctor would discharge the patient. Most of the patients in the closed side are bipolar (with hallucination or psychosis) or schizophrenic. A few of the patients have been in jail for murder. If you met them on the street, you would probably consider these patients abnormal.
As a whole, it was a fun rotation. I got to do my own thing without a higher up breathing down my neck. I had hours to talk to patients and to write notes. In the afternoon, I talked to the attending a little bit regarding the patients.
I actually preferred being on the closed side rather than on the open side. In the open side, I hear the same story every single day:
I am so sad. I want to kill myself. I overdosed on alcohol and benzodiazepines. (Not a good combination at all.)
Not to trivialize what the open side patients are going through but it is booooooooooooring.
In the closed side, I get to hear a new story every single day! That is why whenever I arrive in the morning, I go to the closed side first to see what’s going on.
Michael Jackson died from a “nucleus” bomb. I’m pregant since 2002, with 6 babies, a goat, a cat and a snake. Jay-Z stole Beyonce from me. I have secret files from NATO.
I could probably write an award-winning fiction with the things I hear.
A lot of my peers were quite scared of the patients on the closed side. As for for me, I wasn’t so scared. I was more intrigued. (Maybe I am crazy, but then who isn’t a little crazy.) Don’t get me wrong. That doesn’t mean I’m carefree. I was always aware of my surrounding because these people could snap at any moment. (One of the patients that I thought was totally harmless tried to rape another patient over the night.) If they were to attack me, I would have been fully prepared. Usually, they are on their best behavior so they can leave as soon as possible.
I have tons of stories to tell if you want to hear it (just let me know in the comments and I may write a separate article):
- how I got three girls to synchronize dance and sing for me — which disrupted the whole psychiatric ward
- how I defrosted a frost maiden and she could not stop asking for me
- how pretty much half the girls in the closed side kept wanting to see me
- how I stared down the baddest, most out-of-control patient and got him to back down
- how I knew there are ghosts in the psychiatric ward
- how I stopped one patient from murdering another patient
- what the heck is a “nucleus” bomb and how did it kill Michael Jackson
- how my smart phone absolutely floored John Nash
Order in the … Court?!
Not only did I learn about medicine, I also learned about law. Since many patients are kept in the hospital against their will (even those in the open side), they may go to court to get released. Every Tuesday morning, the judge and his cronies (i.e. bailiff, transcriber, lawyer x2, etc.) would come to the hospital and hold court sessions for each patient who stayed in the ward for 2 weeks or more. I may have learned more from the court sessions than from the rotation itself. These are what I learned:
Lesson #1 – Most People Are Timid Around Authority
Strangely, most patients agree to remain in the hospital until the doctor releases them. These are the very same patients who keep complaining about wanting to leave. My guess is that most people are too chicken to stand up to authority — whether it is a judge, a doctor, a medical student, etc. Patients were asking ME for permission to go back to their rooms.
Lesson #2 – Do Not Trust the Public Defendant
The public defendant is basically the state-appointed lawyer for patients. He is supposed to represent the individual wish of all 10 patients. Let’s assume that he shows up one hour before court begins. Do you think he seriously has the time to prepare 10 different defenses in that short time-span? I seriously doubt it. The defendant’s salary is the same no matter if he fights for 0 or 10 patients. So why do extra work? I cannot prove this for a fact, but I do have a strong suspicion that he urges all patients not to fight. Even if this guy was to fight on the patient’s behalf, he would do so only half-heartedly and would not rock the boat too hard. This guy has been working with the same judge and cronies for I-don’t-know-how-long — possibly years. Why spoil the sweet relationship for a crazy person, right? This may explain “Lesson #1.”
Lesson #3 – Hire Your Own Lawyer
If you ever find yourself locked up in a psychiatric ward without your consent, hire your own lawyer. The only case I saw where the patient successfully fought for his freedom was when he hired his own lawyer. Make sure this lawyer is okay with fighting hard and fighting fierce. Make sure the lawyer is not afraid of the judge. Remember, the lawyer works for your money, not to be buddy-buddy with the judge.
Lesson #4 – If You Are Crazy, Shut Up!
Crazy people say the craziest things. (I gave you some examples in the previous section.) Crazy talk does not necessarily mean you are a danger to self, others, or property, unless you specifically threaten someone. However, crazy talk does annoy the judge and may persuade him to rule against your release. For the brief moment you are in court, resist talking about NATO, cracking spy codes, and alien abductions. Instead, the only thing out of your mouth should be “yes, your honor” or “no, your honor.” Those two phrases will get you through court in most situations.
How to Get Through Psychiatry Rotation in One Piece
Although I make the rotation sound fun, you do have to be constantly be on your guard. The patients are unstable, volatile, and can turn on you at any moment. Even residents have been attacked in the past. It kind of helped that the patients all thought I knew karate, so they didn’t want to mess with me. (Actually, I know tae kwon do.)
The best way to avoid receiving or inflicting physical harm is to be non-threatening. Speak in a calm voice. Don’t make yourself the enemy. The phase, “I’m just a medical student. You have to check with Dr. so-and-so.” is always a safe answer. This way, the patient won’t feel that you are the reason for her unhappiness and won’t lash out against you violently. Always give yourself an out. Stand closer to the door. If you can, try to have someone else with you (i.e. student, resident, attending) whenever you are around patients.
Don’t be afraid. There are cameras everywhere.
The medicine aspect of psychiatry was not too bad. Make sure you know how to diagnose and treat depression (SIGECAPS), bipolar disorder (DIGFAST), and schizophrenia. If you do, you’re set for pretty much any patient you see.
Books for Psychiatry
You don’t need a book for this rotation. It would be nice to have one, but you definitely don’t need one. Psychiatry is one of the easier sections on COMLEX. To prepare for COMLEX and COMAT, the following resources are more than enough:
- First Aid for the USMLE Step 1
- Master the Boards USMLE Step 2 CK (MTB 2)
- Master the Boards USMLE Step 3 (MTB 3)
- online question bank subscription
If you attend UMDNJ-SOM, the shelf exam is a specially-written departmental exam. It is not COMAT. Therefore, your best bet is to get your hands on the circulating study guide. Ask your friends and classmates for it.
If you passionate about psychiatry and want to impress your attending, bring the First Aid for the Psychiatry Clerkship with you.
First Aid for the Psychiatry Clerkship
This book is amazing for a third-year or fourth-year medical student. I brought this book with me to rotation. Whatever did I not know, I easily looked up. When I first started, I used the book to help me conduct a proper history:
Your chart says you have major depressive episode. (So I flip to the depression part of the book.) So in the last 24 hours, did you sleep more than normal or less than normal? Do you still do the things you enjoy? Do you feel guilty? Blah, blah, blah … (Remember SIGECAPS for depression.)
And based on your history, does the patient meet the criteria?
If you are familiar with the First Aid series, you will be familiar with the way information is presented: in outline format. First Aid for the Psychiatry Clerkship is pretty good when formulating your plan. For example, the treatment for depression have many different choices. Which one do you use first? SSRI? SNRI? TCA? Bupropion? The book does go over the pros and cons of each class of medication so you can make the right pick.
The rule of thumb for choosing drugs is to pick the cheapest first and then pick the safest. Notice that I have “cheapest” before “safest.” Welcome to the world of medicine, the world of business.
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)
As of July 2013, the American Psychiatric Association just came out with DSM-5. For those of you who do now know what DSM is, it is basically the official go-to guide that almost all psychiatrist use to diagnose and treat. A lot of the current psychiatry review books are based on DSM-4 (such as the one mentioned above). So I cannot say for sure if you should get First Aid for the Psychiatry Clerkship, DSM-5, or both. I’m guessing that all hospitals are already using the DSM-5, but the shelf exam and licensing exam may be out-dated and test you on DSM-4.
Now that I think about it, if you really want to become a psychiatrist, you might as well just buy the latest book — Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.
Oh well. This is what you get when a specialty is based on pseudoscience. A bunch of guys and gals sit around and discuss what should be classified as a disorder and what shouldn’t. Once a decade or so when they change their mind, you’ll have to change your book.
Try to have fun. Unless you’re going to psychiatry (or if you’re going crazy), you may never get this experience again.
This article is part of the How to Survive Medical School series. Click on the link if you want more tips and hints about surviving academic hell.