It is no surprise that one’s experience in residency is directly related to one’s ultimate career path. When I applied to residency, it was very important for me to find a program that was well aligned with my interests. I chose to train at Johns Hopkins because there is a strong emphasis on the relationship between research and patient care. This was appealing to me because I was undecided on my eventual career, but I knew for sure that I wanted some combination of the two.
As a PGY-II resident, I spend most of my day caring for patients in an inpatient setting. A typical day on inpatient psychiatry begins around 7 a.m. I arrive at work with enough time to review the events of the previous night, check outstanding laboratory values, and grab a cup of coffee with one of my colleagues. By 8:00 or 8:30, it is time for rounds to begin. During rounds, we get a multidisciplinary report on all patients from nursing, social work, and occupational therapy; interview each patient; and decide on a treatment plan for the day. Interspersed between narratives of the previous day and other patient issues, there is a fair amount of teaching as well.
This morning, we had a lengthy discussion about a patient who has been a diagnostic mystery since admission. The only things we know about her are that she was recently discharged from another psychiatric hospital with a diagnosis of schizophrenia, was floridly psychotic in our emergency room, and is easily agitated. We were initially treating her primarily with antipsychotic medications, but when the medications wore off, she remained markedly delusional and her condition seemed to worsen with time. Developing a treatment plan became very challenging and was a constant source of debate as we had very little background and collateral information. A few days into her treatment, we considered reformulating her illness as bipolar disorder with psychotic features. We started her on lithium, and she has begun to improve. All year long, we have been taught the importance of making a diagnosis of mood disorder in patients who present with psychosis, but it was not until I saw my patient improve that I understood why.
Each day after rounds there is a teaching session of some form including grand rounds, a research conference, PGY-class-specific didactics, psychotherapy conference, journal club and Service Rounds, the Chairman’s weekly teaching of residents. Today I attended a lecture for the PGY-II class on schizophrenia. The lecture was given by an attending active in schizophrenia research but who, like all faculty here, attends on the inpatient service as well. She taught us the background of the disease, what is known about its etiology, and areas of ongoing research. I left this lecture with a better understanding of these aspects of schizophrenia; I was also reminded of how little is known about it. By far the most striking element of the lecture was this attending’s excitement for research and how caring for this patient population motivates her.
After lecture, I spent some time trying to accomplish work outlined for each patient in rounds. The afternoon’s biggest task was working on role induction with one of my patients, a man with chronic pain who has been extremely resistant to our treatment plan. He presents a list of demands each day. The day before, he spent his occupational therapy time looking up articles on the Internet justifying the treatment of chronic pain with heroin. This morning on rounds, I had been feeling frustrated with his progress and somewhat directionless. The Chief Resident suggested that we meet with him together and explain to him the importance of his role as a patient. Our discussion went surprisingly well. During his transformation from client to patient, I was able to gain more control over the situation and create a therapeutic alliance with him.
By the time I finish my work, my day will probably end at 7 p.m. I end most days presenting a new admission to the attending, dictating discharge summaries, returning phone calls, or talking to family members waiting to discuss the care of their loved ones.
Over the course of this past year, I have been introduced to many clinical aspects of psychiatry. In the process, I have seen how research can inform clinical decision-making, and I have seen the need for ongoing investigation. I have been mentored by physicians who are successful at balancing clinical practice with a career in research. While my future role in psychiatry remains largely undefined, it has become clear that after 4 years of training, I will be prepared, like my mentors, to interweave research and clinical practice in a way that allows each to enrich the other.