Likes and Dislikes in Psychiatry

Finishing my Psych block, time once again for a reflection on the rotation with my "Likes and Dislikes" series.

1) Oh regular hours, how I missed you

After months of long, drawn-out hours, Psych has been an oasis in the desert. My days were typically 8-9 hours long with the odd day ending quite early. Start times were reasonable. Even the 24-hour call shifts weren't bad, at least by comparison - they were technically home call, so I got to leave the hospital on occasion, and generally got more sleep than on other rotations. I had the odd shift where I got only a small amount of rest, but it didn't feel that exhausting, maybe because I was rested going into it and had time to recover afterwards.

You never quite realize how tired you are until you're not tired and on Psych, I felt rested for perhaps the first time in months.

2) Once again, I like talking to patients

This long into clerkship, some themes are start to reoccur, and this is definitely one. When I can help a patient just by talking to them, I feel great. This is what I got into medicine to do! Psych provides a lot of those opportunities. Even when counselling isn't the main role Psychiatrists fill (other mental health workers seem to do that more often), it's a big part of a lot of interactions with patients and as a result, I thoroughly enjoyed those interactions.

3) Well, maybe not all patients...

The one part about Psych and patient interactions I didn't like was that the exchanges often had an adversarial component to them. When many patients are being admitted to hospital against their will, it kind of comes with the territory. The mental chess that gets played in some cases - while extremely interesting - was also rather draining. I understand that the conflict between patient and provider has a purpose, and that in working against a patient's wishes the physician is doing their best to help the patient, but it's not necessarily something I want to be doing on a regular basis.

It became obvious to me fairly quickly that my preferred patients were those who had ego dystonic conditions - the ones that they want to fix, like depression or anxiety. Individuals who didn't recognize or didn't want to fix their mental health issues weren't as interesting to me. I'm glad there are people dedicating their lives to helping these individuals, because they do need help, but I'm not sure I want to be one of them, at least not on this frequent of a basis.

4) The Happiness Test

I find Psychiatrists in general to be a bit of an eccentric group, so it's sometimes hard to tell their emotional state, but for the most part, the people I interacted with passed this test with flying colours. They were happy! Not joyous per se - this wasn't rainbow sunshine land like Peds was - but they seemed contented at the least.

I wrote off Psych as a potential specialty to match to almost immediately. The reasons behind that choice seem misguided and trivial now - if I had to give a Top 5 of specialties to match into right now, Psychiatry would almost certainly be on there. They say you can't really tell if you're a fit for a specialty until you see it first-hand. In this case, I agree.

Mental Health and Resources - Addendum

Since my last post, I've had a few opportunities to chat about the state of mental healthcare in the area, particularly what could be done to improve the situation. It's in the news a fair bit now, so it's come up in conversation a lot, particularly while on my Psych rotation. One idea that came up was increasing Psychiatrist work hours.

It's a valid thought. Psychiatrists do work fewer hours than most other physicians, especially hospital-based physicians. If any physician can be told that they need to work longer hours, it may be Psychiatrists. However, I'd like to push back against that notion for a few reasons.

First, while Psychiatrists work fewer hours than many other physicians, is that because Psychiatrists are working too few hours, or because other physicians are working too many? I'd argue it's the latter. Psychiatrist hours still average over 45 a week, not much below that of other specialties, particularly office-based practices. Given overall rates of physician burnout and unhappiness with work-life balance, asking Psychiatrists to work longer hours would likely help one problem by causing another.

Second, while no physician works optimally when tired, tired Psychiatrists can be particularly troublesome. Psychiatrists have to be careful not just with their clinical decisions, but their words as well. Emotional lability increases with exhaustion or chronic mental fatigue - a bad thing for all physicians, but particularly for one who has to stay mindful of their phrasing whenever they interact with a patient. With non-psychiatric patients, words matter of course, but the margin for error is much greater - a poorly phrased statement can typically be apologized for, clarified, or otherwise explained without enduring consequences. Not so with some psychiatric patients.

Lastly, there's only so much additional hours from Psychiatrists will do to help. It wouldn't help with inpatient services. It wouldn't help with community supports. It wouldn't help with long-term care availability. At best, it would help reduce outpatient wait times. That's still a desirable outcome, though I doubt that longer hours for Psychiatrists would be anywhere near enough. If wait times could be reduced from 1 year to, say, 9 months, that would be a positive change, but 9 months is still far too much time. 

It's a tough situation. As our society increasingly accepts mental health as an important priority, demand for mental health services will also increase. Realistically, all options should be on the table, including longer working hours for Psychiatrists. However, we need to avoid band-aid solutions and "work harder" is pretty close to my definition of a band-aid solution. Other approaches are necessary and, I believe, should be explored first before simply asking current workers to do more.

Mental Health and Resources

I'm on my Psych block now. I'll give my final thoughts on the rotation when I'm further into it, but for now, I'd like to take a minute to express my deep frustration with the availability of medical services in this country and my area in particular. Long story short, we need more beds, more services, and more resources in general.

I have plenty of frustrations about the medical system in general. That's kind of the point of this blog, to get those frustrations out constructively. A lot of my concerns relate to the actions of physicians as a group, as well as physician-dominated organizations including medical schools. I think we, as a profession, hold a lot more blame for the problems in medicine than we're generally willing to admit, and that we have a lot more power to push forth positive change than we currently exercise. I try to advocate for internal changes within the profession of medicine ahead of or in conjunction with changes outside of the medical profession. I especially try to avoid lobbying for more money to be thrown at any particular problem, because resources are finite and while money can paper over a lot of structural problems, they don't solve them either. Those structural issues need to be tackled regardless and doing so may remove the need for more funding.

Not so much when it comes to mental health. The state of mental healthcare in my region is receiving a lot of scrutiny, justifiably, due to a number of frankly horrible situations that have occurred recently or not-so-recently. A lot of these criticisms have been directed towards the government, particularly the provincial government, and I largely agree with those criticisms. Some of the criticism has been directed towards the hospital I'm training at, the physicians and other healthcare workers involved in care for those with mental health, as well as the school I attend. For once, I can't agree with these criticisms. The hospital has clearly tried to prioritize mental health. Employees and physicians have largely just tried to make the best of a bad situation, accepting what is objectively a poor situation because no better alternatives exist. Even the school has gone out of their way to increase the number of Psych residents to help with the workload and encourage more Psychiatrists to stay in the area.

When valuable 1-on-1 therapy is virtually impossible to achieve without insurance or significant independent funding, when long-term care facilities are routinely unavailable, when the mental health ward is operating above 100% capacity (even after accounting for those waiting for long-term care), when wait lists to see an outpatient psychiatrist are on the order of months or years... even monumental changes in the organization of services aren't going to cut it.

Psychiatry does have its share of problems that can be laid at the feet of physicians, of that I have no doubt. However, it's pretty clear that more resources are needed. I don't see mental health being substantially improved without more inpatient beds as well as more supports both in and out of the hospital.