Once I knew that I was going to be a psychiatrist, there was no question in my mind I wanted to be an academic one. The vigor involved in the academic quest for knowledge, the research enterprise, the teaching, and the hanging around with bright people seemed like the perfect environment for me. And for the most part I haven't strayed from that mission, although my priorities in life have shifted. Before marriage and kids, my life ambition was to make a significant contribution to the field of psychiatry (more honestly, I must admit I wanted to find a cure for schizophrenia). Working evenings and weekends was of little consequence to me as I rose quickly on the academic ladder. Now with a wife and three kids, my priorities have shifted, and each day becomes a balancing act of managing my time commitment to family and to career. Here then is a typical day for me, complete with my thoughts and reflections as I go through it.
07:00 A.M. Electroconvulsive therapy (ECT)
I start my day with ECT at this early hour because it is the only time we can get scheduled with anesthesia and the recovery room. The procedure goes smoothly, and the psychiatric resident and medical student find it fascinating. I enjoy the looks of amazement and relief on their faces, as they learn that ECT is not a "bad" procedure. Everyone, it seems, must witness at least one actual ECT before they can lay to rest the horrific ECT scene from "One Flew Over the Cuckoo's Nest."
I arrive at my office, and the site of journals, articles, memos, and "things to do" paperwork piled in stacks, sliding off one another, and generally cluttering the place is disheartening. The furniture in this room looks as if it is weeping under the burden of this paper mess. Visitors to my office have actually laughed out loud when they first see it. This is where the family/career equation truly begins, for I must decide which of the extremely urgent "must do" projects I need to tackle today. I could, literally, be here for weeks without interruption if I decided to do half of it. Any day of the week, I can decide to go home late if I choose to do more rather than less. After a quick scan of three piles in the extremely urgent stacks, I pick a few things I hope to complete and set them in the tiny open space on my desk. These tasks include: completing a clinical management guideline for depression for my hospital (federal hospital requirement—has been due for two years now, but I am told it must be completed by end of the month), completing a psychiatry resident evaluation (due last week), work on emergency detention of dangerous patients policy (to be discussed at hospital manager meeting today), and review research data (to be discussed in teleconference today). Today will be a good day if I can get just one of these things done. I am always hopelessly behind. It's funny that I was able to keep up with the duties and tasks in medical school, residency, and fellowship, but have not found a way as a faculty member.
8:00 A.M. Hospital rounds
I am on the adult inpatient psychiatric unit now, where I serve as clinician (hospitalist) and medical director. I have a medical student and first-year psychiatry resident with me as we round on established patients and work up new ones. Although the pace is frantic and busy, time slows down when we are in with the patient. Here, I am truly in my element. I am focused, sharp, attentive, and creative. I love being a doctor, a psychiatrist, and a healer. I can spend a lot of time with a patient without noticing it. After being a psychiatrist for 14 years, I still find people utterly fascinating. I love "turning on" the students and residents to this world. After each patient we chat for a moment or two, and this is where teaching and learning are at their peak. This is where the pages of books, manuscripts, research reports, and lectures come alive in this living, breathing person … this patient. Although this part of my job is thoroughly enjoyable, and I sometimes get lost in a concept, I am aware of the family/career time continuum in these teaching moments. Basically, any minutes I spend teaching add up to my total minutes available for work that day, and thus add to the grand sum. Given that on most days the time required for my various duties is more than I have allotted for work, teaching becomes a liability. Throughout my academic career I have heard the phrase "protected time" in reference to academic activities such as teaching (or research) that would be shielded from other clinical, administrative, or departmental duties. Through logic or reasoning I can see this is possible, but on a practical level, I have never experienced it. In my experience as an academic psychiatrist, I have been able to enjoy all the teaching or research activities I want, as long as they are added to my already supersaturated schedule.
9:45 A.M. Interdisciplinary rounds
Psychiatrists, psychiatry residents, medical students, nurses, nursing students, social workers, social work interns, occupational therapists, occupational therapy students, and clinical specialists discuss all patients in an interdisciplinary, collaborative framework.
11:30 A.M. Behavioral services management meeting
As medical director of adult psychiatry services, I enjoy being on the leadership team for clinical enterprises. Attending this type of meeting, however, I find tolerable but not enjoyable. Finances, length of stay, action plans, clinical management guidelines, utilization review, etc., all have obvious importance in the scheme of things. I guess I feel more like a businessman and less like a healer when doing the administrative part of my work. I eat lunch during the meeting, getting some momentum on the family/career time equation.
12:55 A.M. "5-minute break"
This is when I usually catch up on articles and recent science by quickly scanning abstracts, medical letters or reviews in psychiatric newspapers. At one time I had a goal to devote one-half day per week to keeping current on the field of psychiatry by reviewing what was being published. Reading during 5-minute breaks or while on telephone-hold has been my reality.
We have a very psychotic, delusional man on the unit, and we are meeting with his family members to discuss the situation. The patient wants to leave, has no insight into his illness, and is markedly delusional. The family is trying to convince him to stay and take appropriate psychiatric medications. The medical student becomes quite involved with this situation and is clearly worried that the patient will leave. The patient, in fact, decides to leave against medical advice, despite the painstaking efforts by others. The student is crushed. I would like to have time to discuss this with the student but must leave for my next appointment.
2:00 P.M. Research conference call
This is time to discuss a multicenter research project for which I am a co-investigator. I haven't prepared for the meeting, and it shows when we begin discussion. Nevertheless, I really enjoy the teleconference, as my colleagues are such bright, energetic, and academically robust people. This is what academic medicine is all about: being part of a team, exploring the cutting edge of a concept, collecting data and interpreting the results. The time spent in this activity feels very self-gratifying for me. I do, however, need to leave halfway through the call in order to reach my scheduled seminar in time.
2:45 P.M. Psychotherapy seminar
I am teaching supportive psychotherapy to third-year psychiatry residents. They really enjoy the course, and I feel a part of their growing confidence in becoming psychiatrists. They are actually learning how to do therapy, which sadly is becoming a dying art among psychiatrists.
4:30 P.M. Hospital consult
Unfortunately I was paged during the psychotherapy seminar and must now return to the hospital to do a psychiatry consultation on a patient in the intensive care unit. This adds significantly to the denominator of the family/career equation, and I must call my wife to let her know I'll be late for dinner. Driving to the hospital I find myself fantasizing that the consult will be for a comatose patient with some intermittent agitation, as these are usually expedient to perform. It is a greedy fantasy … I simply want to get home to my family at a reasonable hour. Unfortunately, I arrive at the hospital to find I must sort through a difficult, suicidal patient (patient had intentionally overdosed on medications) who wants to leave against medical advice and a torn family (split on support of patient's decision to leave) at the scene. I take a deep breath, enter the scene, and exit the family/career time continuum. This is going to take a while.
A few minutes after drifting off to sleep, I was bombarded by the sound of my pager. (I take call every other weekday and every third Saturday). A young man on the unit is becoming loud, agitated and making some threatening statements. This is the worst kind of call to get because if I am not successful with assertive medication management by phone, I will need to travel back in to the hospital for a face-to-face encounter with the patient in order to utilize seclusion. After discussing the situation and giving some orders, I have trouble falling back to sleep. To relax, I program my mind to imagine I will sleep through the night, with no further intrusions …
Overall I feel fulfilled with my mission to teach in the context of providing good clinical care, and this part of my life as an academician is most satisfying. I am, however, chronically falling short of my goals to learn from and contribute to the scientific enterprise. It's a good thing that my wife and kids don't hold this against me.