Psychiatry Residents Coming and Going: Get What You Need

It’s that time of year when we graduate current residents and welcome the new ones. The graduation event was a huge success. There goes 14 of the most outstanding psychiatrists we’ve ever had the honor to work with. It’s a lucky world waiting to receive them. There were many awards which are always fun to give and receive, especially for me.

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PearlsAnd the incoming residents will need a little guidance, pearls of wisdom from the generation of psychiatrists who have been residents themselves…and don’t really remember much about it. It’s kind of a blur. Anyway, I offer my deathless prose, always to be remembered as former trainees dandle their grandchildren in front of the fireplace, perhaps accidentally booting them into the cold ashes because they could never learn how to keep it stoked.

Some psychiatrists have said that all mental disorders are brain disorders and there should be greater emphasis on neuroscience in residency education and in practice. DSM5

See if this perspective makes sense when you’re in the ER doing your best to evaluate an intoxicated patient who is unemployed, homeless, in chronic pain, doesn’t qualify for ObamaCare, hints at overdosing if not admitted, has assault charges pending, was beaten regularly by his father, has been married and divorced 4 times, and is surrounded by two of his ex-wives and a daughter who thinks he’s a saint but wants him committed so he can finally get some help, and who needs to be in court for a custody hearing in two days.

Syst Psy Eval ChisomLyketsosI’m not saying neuroscience isn’t important because it certainly is. On the other hand, paying attention to “old” psychodynamic concepts like transference and countertransference, managing boundaries, and recognizing defense mechanisms is still just as important. The book, “The Perspectives of Psychiatry” by Paul McHugh and Slavney still makes sense: some psychiatric disorders are best considered from the Disease Perspective, e.g., delirium, schizophrenia, bipolar disorder. But the other Perspectives, Life Story, Behavior, Dimensional are also real. They’re not mutually exclusive. And I was in the audience at a professional meeting where Dr. McHugh himself said the DSM is “a guide, not a god.”

Psychotherapy can be a neuroscience intervention because it changes the brain. According to Karlsson, about 20 studies have been done in the last two decades demonstrating that talk therapy can induce changes in the brain similar to antidepressant. Different types of psychotherapy such as Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) can alter brain function in a variety of psychiatric disorders including but not limited to depression, obsessive compulsive disorder, posttraumatic stress disorder, and panic disorder. Further, dialectic behavior therapy (DBT) led to a decrease in the hemodynamic response to negative stimuli in the right-sided anterior cingulate, the temporal and posterior cingulate cortices, and the left insula. Karlsson also points out that psychotherapy can lead to changes in gene expression through learning, changes in the strength of synaptic bonds between nerve cells and by causing changes in the shapes of neurons [Karlsson, H., MA, MD, PhD (2011). How Psychotherapy Changes the Brain: Understanding the Mechanisms. Psychiatric Times, UBM Medica. 28.].

Taking care of yourself is hard during residency. Consider Mindfulness-Based Stress Reduction (MBSR). One strategy from MBSR is S.T.O.P. (Stop, Take a breath, Observe what’s happening inside and outside of you, Proceed). You can do this while walking to the ER for that 3rd consult in the middle of the night. Further, Dr. Richard Davidson, PhD, has discussed the evidence suggesting that meditation may change the way the brain processes emotional stimuli.

Mindfulness has the potential to to be a tool against physician burnout.

And remember H.A.L.T. which I guess they’re not teaching trainees anymore. Try not to let yourself get too Hungry, Angry, Lonely, or Tired.

Try to keep a sense of fairness and good sportsmanship because you never know when you’re going to lose a game of Matball and thoughts about pranking the winner’s trophy intrude. Good luck.

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Comments

  1. One of the earliest neurobiologyenvironmental paradigms studied in psychiatry was the behavioral and neuroendocrine changes that happens to humans and non-human primates in high stress environments. In my experience, all of the medication and mindfulness techniques in the world can’t compensate for overwhelming stress. That is true if I am talking to a homeless guy with diabetes who is living under a bridge or a physician who is working too long and too hard.

    I tend to recommend addressing the environmental issues before anything else these days. I have talked with too many people who thought I could help them endure chronic stress that nobody could ever tolerate. In the case of residents, I understand the training schedules have been modified to prevent the all night call and admitting patients the next day until 5PM that I had to put up with. Hopefully faculty will be able to say what is realistic and whether the rules are being followed.

    Old ideas like needing to tolerate extremely stressful training environments – die hard.

    Like

    • Well said, George. In my first year of residency, I occasionally would nod asleep, face forward, in my dinner after one of those long calls you mentioned. Once, to my embarrassment and to my wife’s distress, I even forgot our wedding anniversary.

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