Friday is probably the busiest and most representative day for me. I start at 8:00 A.M. by attending on the inpatient unit, where I supervise 2 residents and 2 medical students. Our service is typically very hectic, with approximately 12 to 16 patients on any given day and a very high level of acuity. We see everything from severe eating disorders to alcohol detox patients, and most patients have, in addition to complex psychosocial issues, reluctant insurance companies. My biggest challenge becomes finding a way to take care of patients, get their stay paid for, and all the while find time to teach the residents and medical students. Unfortunately, when things really get busy, the only teaching that goes on occurs in the heat of the battle. I use the word "battle" only somewhat metaphorically, because at times it really does feel like a war zone up there. The patients often have severe personality disorders and substance dependence and resist appropriate treatment. I spend a good deal of time trying to manage their interpersonal issues, which if untended can wreak havoc on the unit. Meanwhile, I am on the phone with insurance companies everyday, trying to justify the hospital stay of an obviously acutely ill patient. Thank goodness the nursing staff and residents are all top-notch. Otherwise it might really be untenable.

At noon I rush back over to the psych department building across the street from the hospital, to chair the curriculum committee meeting which typically meets at that time. I was asked to be the chairperson because I have shown an interest in teaching but also because I am junior faculty, and I suspect no one else wanted to do it. I happen to enjoy it, and I believe that the changes we are making in the curriculum will do some real good. The meetings are usually attended by the Residency Training Directory, one or two faculty, and a handful of bright-eyed, eager residents, without whom almost nothing would get done. We eat lunch together and plan the changes to improve the classes and structure of the residency program. There's little time for socializing, because at 1 P.M., I'm back at my office upstairs to supervise the psychopharmacology outpatient mood disorders clinic.

I supervise two residents between 1:00 P.M. and 5:00 P.M., during which timethey see returning patients for medication management every one-half hour or new patients on the hour. The resident does the initial assessment, or for new patients the initial workup, and I step into his/her office towards the latter half of the session. The resident presents the patient, typically right there in the room with the patient present, and the three of us strategize together about the best treatment options. I always ask the resident what he or she would do before giving my viewpoint. If the resident's plan seems reasonable, we go with it. If it needs improvement, I try to find a diplomatic way of suggesting another plan and give the reasons why. The residents tend to like this clinic because it forces them to think on their own about what to do, and it teaches them to formulate a case and present it on the spot. The patients seem to like the style of the clinic as well because everything is discussed in their presence, so the thought-process becomes transparent to them, and they learn about their illness. I like it because it very much suits the collegial style I prefer with my patients, as opposed to a more dependent, paternalistic approach, which doesn't suit my personality.

With the structure of the outpatient clinic as it is, I have about 10 minutes at the beginning of each hour which is open. I fill these 10-minute increments with a variety of tasks, including seeing subjects enrolled in our medication trials. Usually subjects require a quick M.D. review of symptoms, but sometimes the examination is much longer, including a full physical exam and EKG. I do the EKG using a portable monitor, the results of which are then relayed by phone to the industry-supported EKG hub. I will often do the EKG first, then, while the subject is dressing, go see a patient with the resident. When I return from seeing the patient, I can finish with the research subject, and so on. One of our industry-supported studies requires me to give an injection of medicine in the patient's buttock after carefully mixing the medication from the vial. Fortunately, this task doesn't take too long. On the rare occasion when I have a 10-minute increment free, I try to answer e-mail or finish up clinic paperwork. When 5:00 P.M. finally arrives, it seems it was an eternity in coming, and I am exhausted. For a few weeks I saw a psychotherapy patient who is a teacher and couldn't make any time other than 5:00 P.M., but I quickly realized that I was good for nothing at that hour, and we rescheduled. At 5:00 P.M. I say good-bye to the residents and pedal home on my bike, where my husband and daughter wait for me.

When I reflect on the day I just described, I realize I've portrayed a schedule that is hectic and not always pleasant and leaves no room, as I'm sure you have gathered, for the traditionally quiet pursuit of scholarship, in the form of reading, writing, or research. Nonetheless, it is a purposeful day, and I end it feeling that I have truly accomplished something in the span of nine hours. As for my research and writing, it will have to wait for another time, perhaps a few hours on the weekend if I can bear to spend it away from my family. More than likely I will squeeze an hour in here or there earlier in the week. I am also struck by the variety of responsibilities I have, some of which I never imagined as part of my psychiatric career. Doing EKGs and giving injections are not exactly typical for psychiatric practice, and yet I find I enjoy the variety.

The greatest source of anxiety for me on my job is the lack of big blocks of time to work on the research aspect of my career. Although I am in a "clinical track," I am expected to produce "scholarly work," and I enjoy such endeavors. But finding the time to do them remains a challenge, particularly when I want to spend time with my family. Sorting out this balance is an ongoing challenge for me.