The Life Raft for psychiatry

September 29, 2008 at 7:21 pm (Life Raft)

Few fields of medicine are as unique and exciting at psychiatry.  Where else are you going to find a 34-year-old man talking to his penis and telling it secrets?  At the end of your shift you will come home wanting nothing more than to tell all of your friends and neighbors about all of the interesting people you’ve met throughout the day.  Don’t go breaking HIPPA and other codes of decency just yet.  There are several important rules of etiquette that apply more so to psychiatry than to any other specialty.

First off, never say that a patient is “crazy,” “bizarre,” or even “psychotic.”  These terms stigmatize mental disease and place blame on the patient for a neurochemical disorder that could just as easily affect any one of us.  Instead used terms like “inappropriate behavior” or better yet, cite specific examples of things that the patient does, such as “responding to internal stimuli.”

Second, never say that a psychiatry resident is “crazy,” “bizarre,” or “psychotic.”  For whatever reason, the strangest people in medical school generally end up as shrinks.  And as the book Mount Misery tells us, psychiatrists will specialize in their defects.  There are many stigmas against the field both within medicine and among the lay public.  And you certainly don’t need to contribute to them.

Television shows such as Dr. Phil leave us believing that anyone can treat mental disease and has turned us into a nation of armchair therapists.  Encroachment on the field by social workers, life counselors, and a variety of psychologists who use any title such as “school psychologist” make the specialty seem easy to enter.

Among other physicians, psychiatrists are seen as being helpless to treat medical conditions.  I wanted to apologize to our consultants every time we had to call them because our residents could not manage blood pressures of 150/90.  Whenever a patient attempted suicide by cutting his wrist and then presenting to the psychiatric hospital, he was immediately deferred to another physician to suture the wound closed.  The other specialists were generally greatly annoyed that anyone with a title of “M.D.” could be unable to manage mild hypertension or mildly elevated blood sugars.

What you need to know to succeed on your clerkship:

1.  Drugs, drugs, drugs.  With the exception of electroconvulsive therapy, there are no procedures to master in this rotation (as if you’ll even see ECT during this rotation).  The sole method of treating mental disease amongst psychiatrists is to use an armory of medication in the hopes that the various neurotransmitters are put back into proper balance.  I suggest that you either find or make a list of various psychotropic medications, their mechanisms of action, their indications for use, and the side effects specific to each drug.  Such a list of drug names would not be very long, but should contain a detailed amount of information.  For example, clozapine  is a very effective medication against schizophrenia.  However, its most dangerous side effect is agranulocytosis.  I can guarantee you that you will be asked about this drug at least once.

2.  DSM criteria for diagnosis.  In psychiatry, the majority of diagnoses are made solely upon history.  There is no physical exam, and anyone who tells you otherwise is lying to himself.  There are however a battery of paper-based scoring test that are used in the management of a patient’s condition.  Rarely are labs ordered.  If they are, look to order electrolytes, a thyroid panel, vitamin B1, vitamin B12, urine toxicology screen, and an RPR to test for syphilis.

Several months ago I posted my stories about psychiatry on this website.  They generated quite a bit of discussion amongst my readers.  Here are my previous posts.  I hope that they can create new conversations amongst all of you.

You won’t believe the stuff I saw today
Everyone gets a diagnosis and a prescription
Psychiatrists as shams
You won’t believe the stuff I saw today (part 2)
The fake doctors
Leap Day
How’s that for a can of whoop ass?
You won’t believe the stuff I saw today (part 3)
You won’t believe the stuff I saw today (part 4)



  1. mhf said,

    No mention of how silly administering the MMSE makes you feel?

  2. halfmd said,

    There are more than enough tests (especially among geriatrics) to make me feel silly.

  3. John MacDonald said,

    For what it’s worth, the title “school psychologist” is controlled, by at least two agencies in nearly all states, by both the state’s Department of Education, and by the Board of Psychology, which is usually under the state’s Department of Health. And it’s not that easy to enter. My training was a five year PhD program, with one-year of predoctoral full-time internship (in addition to practica each semester) – but that was a long time ago.

    We serve families of students with disabilities, age birth to 21. Our purpose is to enable them to be as ready as possible for schooling, and to get to them to graduation or age 21 ready to be as independent and responsible as possible. These are complex issues to address, requiring multidisciplinary work. The students we are least successful with in terms of outcomes are students with emotional/behavioral disabilities – these students will often have DSM diagnoses – their post-school employment rates are half that of students with other disabilities. Many have concommitant health problems. This doesn’t mean they are unworthy of the attention of bright people. We need bright people to assist. Just make sure the approaches you use are evidence-based.

  4. Carrie Nation said,

    Your entire blog is confirmation for me that medical doctors, and the pond scum who hope to be one, are no more valuable to our society than personal injury lawyers and auto insurance brokers.

    If your heart for human beings (who you will be caring for the rest of your life) were any less black and cold, you might actually qualify as something terrestrial.

  5. halfmd said,


    Your state must have more rigid standards for school psychologists than mine. Here, we release them after one year of coursework and a community internship. While they are useful for student assessment, I don’t think that they should use the term “psychologist” because it conveys more training than they really have.

  6. mhf said,

    I was under the impression that one couldn’t legally use the title, “psychologist,” unless one had a PhD or PsyD.

  7. partner said,

    thanks you
    You will have to crawl very nice,owe you gratitude..

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