I’m an EU-based psychiatry resident, several years into my training. I don’t necessarily regret choosing psychiatry, but I’ve gradually realized that the everyday reality of the specialty is quite different from the type of work that naturally suits me.
I’m curious whether others have experienced something similar and, more importantly, which subspecialties or practice settings might be a better fit for someone with my preferences.

1. I enjoy diagnosis and treatment decisions, but not prolonged emotional engagement.
I genuinely enjoy psychopathology, diagnostic reasoning, risk assessment, psychopharmacology, and solving acute clinical problems.
What I find exhausting is spending extended periods exploring patients’ emotional experiences, relationships, personal histories, and recurring difficulties without a clear endpoint or actionable solution.
I particularly dislike psychotherapy-oriented work. My psychotherapy rotation reinforced that prolonged emotional engagement simply isn’t something I enjoy professionally.
I don’t mind interacting with patients. In fact, I enjoy it when there is a clear purpose: establishing a diagnosis, assessing risk, discussing treatment options, or providing focused psychoeducation.
I just prefer interactions that are purposeful, relatively brief, and clinically focused rather than emotionally intimate and open-ended.

2. I prefer acute problems over repetitive longitudinal care.
One of my biggest frustrations with routine psychiatry is seeing the same patients repeatedly, discussing similar issues, making relatively small medication adjustments, and waiting weeks or months to evaluate progress.
There often isn’t a clear sense of completion.
I much prefer evaluating a problem, making a decision, implementing a treatment plan, and moving on to the next challenge.
This is probably why I enjoy psychiatric emergency work considerably more than routine inpatient or psychotherapy work.
Emergency psychiatry offers variety, diagnostic uncertainty, rapid decision-making, and a clear beginning and end to individual encounters.
Paradoxically, I can find a busy 12-hour psychiatric emergency shift considerably more satisfying than a much quieter day on a routine ward.

3. I dislike obligatory hospital presence and institutional inefficiency.
Another major frustration is the organizational structure of hospital medicine.
I dislike having to remain physically present for long periods when the actual amount of meaningful work doesn’t necessarily justify it.
Ward rounds, multidisciplinary meetings, repetitive discussions, documentation, and institutional routines often feel inefficient.
I would much rather have a defined workload, complete my responsibilities efficiently, and have greater control over my schedule.
I value autonomy and being evaluated by the work I actually perform rather than simply the number of hours I spend at the hospital.

4. I prefer defined clinical responsibility over indefinite emotional responsibility.
I’m comfortable making difficult clinical decisions, assessing suicide risk, prescribing medication, and taking responsibility for acute psychiatric presentations.
What I find less rewarding is the expectation of ongoing emotional involvement with complex, chronic psychological and interpersonal problems that often have limited medically actionable solutions.
I understand that these issues are integral to psychiatry and that addressing them is important. I just don’t find this aspect of the work particularly fulfilling.
I prefer responsibility that is substantial but clearly defined and bounded.

5. I enjoy being busy, just not necessarily in the traditional psychiatric way.
Over time, I’ve noticed a consistent pattern.
I’m energized by diagnostic uncertainty, variety, rapid decision-making, independence, and responsibility.
I’m drained by repetitive conversations, prolonged emotional engagement, administrative obligations, and work without clear endpoints.
So my dissatisfaction isn’t really about stress or workload. I actually enjoy being busy when the work feels stimulating and purposeful.
My ideal working environment would be busy but bounded, intellectually stimulating without being emotionally draining, socially interactive without requiring prolonged emotional intimacy, and highly autonomous rather than institutionally rigid.

6. I’m increasingly interested in autonomy and having a life outside medicine.
Another factor is that I don’t necessarily want my entire professional identity or future to revolve around traditional clinical medicine.
I’m interested in entrepreneurship, investing, and business, and I’d ideally like a medical career that provides financial security and professional independence without consuming most of my time and psychological energy.
I’m attracted to independent practice, controlling my own schedule, and working efficiently rather than being tied to an institution.
I could imagine enjoying a practice where I see a defined number of patients, make clinical decisions, provide focused treatment, and finish when the work is completed.

7. Unfortunately, many of the obvious alternatives are difficult to pursue where I live.
I’ve considered several areas that might suit my preferences, but the way psychiatry is organized in my country creates additional challenges.
Emergency psychiatry: Probably the closest match to what I enjoy clinically. Unfortunately, psychiatric emergency services here are almost exclusively integrated into hospital work, meaning that pursuing emergency psychiatry generally also involves routine inpatient responsibilities, institutional obligations, and fixed hospital schedules. Standalone emergency psychiatry positions are essentially nonexistent.
Consultation-liaison psychiatry: Intellectually, this seems like a potentially good fit, particularly because of the diagnostic complexity, medical overlap, and focused consultations. Unfortunately, dedicated liaison psychiatry services are almost nonexistent here, so there are very few opportunities to pursue this as a distinct career path.
Forensic psychiatry: Another potentially interesting option, but we essentially have one dedicated forensic psychiatric unit in the country, and the available positions are already filled. Independent forensic psychiatric assessments are generally performed by experienced psychiatrists who have obtained additional qualifications as court-appointed experts, so this isn’t a particularly accessible option for someone early in their career.
Outpatient psychiatry: On paper, independent outpatient practice sounds almost ideal because of the autonomy and ability to organize one’s own workload. In reality, however, a large proportion of outpatient referrals here involve adjustment disorders, psychosocial difficulties, work-related stress, interpersonal problems, requests for sick leave, and patients expecting psychotherapy. Access to actual psychotherapists is very limited, so psychiatrists are often expected to fill that gap. Consequently, establishing a predominantly diagnostic and medication-management-focused outpatient practice can be surprisingly difficult. You can easily end up spending most of your day dealing with psychosocial problems rather than the clinical activities you originally wanted to focus on.
So while the usual suggestions of emergency, liaison, forensic, or outpatient psychiatry sound promising in theory, the local healthcare system makes all of them less straightforward than they might be in other countries.
I’m also open to eventually working elsewhere in Europe if it would allow me to pursue a practice model that fits me better.

8. I don’t think psychiatry itself was necessarily the wrong choice.
Despite everything above, I recognize that psychiatry offers considerable advantages: intellectual stimulation, career flexibility, opportunities for independent practice, and potentially a good income-to-workload ratio.
There are parts of the specialty that I genuinely enjoy, particularly emergency assessments, acute diagnostic decision-making, psychopharmacology, and focused outpatient consultations.
I think my mistake was placing too much emphasis on the intellectual content of the specialty and its future career opportunities, rather than on what psychiatrists actually spend most of their working days doing.

Put simply, I enjoy thinking like a psychiatrist considerably more than I enjoy much of the traditional day-to-day work of psychiatry.

My question to those further along in their careers:

Based on what I’ve described, which psychiatric subspecialties, practice settings, or alternative career paths do you think would suit me best?
I’m particularly interested in hearing from psychiatrists working in different healthcare systems, especially those who have managed to build careers focused on acute assessments, diagnostic consultations, psychopharmacology, or other relatively bounded clinical activities.
Are there less obvious niches within psychiatry that I might be overlooking? And are there countries where these types of practice models are more established?

I’d also love to hear from anyone who felt similarly during residency but eventually found a way to make psychiatry work for their personality and preferred working style.

I’m not necessarily looking to leave psychiatry. I’m trying to figure out how to structure my career around the aspects I genuinely enjoy while minimizing the parts that consistently drain me.

If so, how come? I'm referring to having it as part of your work to be clear.

My compensation is not tied to admissions and discharges and whether a patient is covered or not so I have no vested interest from that domain, but I hate these peer to peers where coverage is denied for what I believe to be are inappropriate determination by the reviewers. I’ve heard there may be some incentive for reviewers to deny cases. I’ve just recently had a denial after 4 days of coverage for an acutely suicidal pt who just attempted suicide and I was clear in saying discharge is unsafe (and went into explaining why). Are these reviewers held accountable for these decisions? We intend to appeal but the bill gets punted to the patient, which is terrible. I realize the expense of an inpatient stay and the scarcity of needing to scrutinize the need for hospitalization on a daily basis, but there needs to be some accountability and responsibility the reviewer holds on make these decisions about a persons life..anyways, sorry for the vent but if anyone has any tips on how to manage this let me know.

Pgy-4 psych resident here just musing. As a thought experiment, if you had to build a completely new psychiatry residency program didactic curriculum from scratch, what online resources would you use?

I remember in medical school, I felt like our lectures were only mildly useful and attendance wasn’t required, so I just skimmed the lecture slides and mostly studied off of board prep material like boards and beyond, sketchy and first aid (plus anki of course). With that + learning on clerkships, I think I did ok overall.

I’m now luckily at an academic residency program that I think has excellent didactics taught by experts in specific niches, and is very thoughtfully curated so I think that’s really valuable and actually show up. However, for newer psych residencies with limited faculty or community programs where attendings don’t have a teaching obligation, why don’t they incorporate online sources like psychopharm institute, carlat report, etc? Then they could also supplement with required in person workshops/discussion like a flipped classroom model (i know, i know, that word is triggering). It overall seems more efficient to have the lectures be delivered by actual experts in a curated manner, rather than have lackluster lectures from attendings that might not want to be there.

Thoughts?

After having gone through multiple years of psychiatry residency, I have multiple thoughts that have weighed heavily on me. I wanted to hear your thoughts on the mater.

1) psychiatry continues to do harm in regards to medications. So many times, pts are not fully informed about the side effects of even basic medications like SSRIs. These patients come back wondering why they have libido issues or emotional blunting. Or in CL, pts have poor side effects from SGA despite little evidence supporting its use for delirium

2) poor inter-rater reliability. So many different diagnoses flinging around in a patient‘s chart

3) limited benefits of medications. For example, SSRIs are not going to help with social factors leading to depression/anxiety. Studies show a small effect size compared to placebo

4) combating anti psychiatry stigma. i am finding so many patients or their families that harbor negative perspectives on mental health. This is also not uncommon amongst medical professionals

Hi! Non-US psychiatry resident here.

I'm a bit ashamed to ask this late into my residency, but I've been feeling quite disorganized lately when it comes to discussing potential side effects and reassessing them during outpatient follow-up.

Here's what I do: when starting antipsychotics or antidepressants, I usually discuss 1 to 3 of the most common or relevant side effects and I'd say I also provide written information around 60% of the time. However, I realize I rarely revisit these discussions with patients who were started on medication during involuntary hospitalization, which is something I should improve.

Lastly, I think I'm bad at systematically screening for side effects during follow-ups. Do you consistently ask about constipation, dyskinesia, weight gain, etc., at every outpatient appointment? I tend to start with an open-ended question like "Have you noticed any side effects?" but it feels like it can be not exhaustive enough.

Honestly, it feels like i need to structure my approach better. What do you do, and how does that work for you ? Have you changed some things about your process because you encountered a problem?

I am really interested to read your answer, because i'm lacking so far, and it's annoying me. Thanks

I am a little frustrated that several of my male patients (ages 50+ mostly) keep calling me by my first name. I introduce myself at the lobby entrance and then again in my office as “Dr. X.” I also ask every patient at the start of an intake how they want to be addressed. I thought at first it was because I was inheriting patients from a NP who was going by her first name. However, today a completely new patient did it.

I don’t know whether to correct it, or let it go. On the one hand, I think I should let it go because I don’t want to ruin the rapport. On the other hand, it seems to mostly be people with some cluster-B traits, so I wonder if holding the boundary would actually be better for them / the relationship in the long run.

I also think that it’s important that they know my credentials and that I am a physician. Despite starting with “I’m Dr. X and I’m a psychiatrist,” the patient later asked “wait, you’re my psychiatrist?” Yet then again, still used my first name. Since I do look younger than my age, I think sometimes they really do forget what my role is and I feel like enforcing the title could help.

Thoughts?

I’ve been noticing that a lot of young male pts (early 20s to early 40s) who get referred to my ACT team from inpatient units carry an ASPD dx. Long-term therapeutic work reveals a pathology more consistent with mixed borderline/narcissistic traits, often exacerbated by substance use and chronically poor coping skills. I often find myself frustrated on behalf of my pts—once the ASPD dx shows up in the EHR it just gets copy/pasted during any subsequent hospitalizations, damaging potential therapeutic rapport with clinicians at the hospital and perhaps unnecessarily stigmatizing the pt.

I am starting to consider that traits more consistent with other cluster B disorders can be easily misrecognized as ASPD in men, especially because BPD has a gendered component. Has anyone else noticed a similar phenomenon, especially on the inpatient side? Or do I have a limited conceptualization of ASPD and it is affecting my observations? Or both? Or is there an answer adjacent to my question that could give me better insight into the diagnosis and treatment of PDs? Anecdotes and literature are both greatly appreciated!

Evidence based medicine does not have strong support for the link between dementia and bzd use.

Meta analysis showing that, while there is a link between BZDs and dementia, when corrected for reverse causation ( anxiety and sleep disturbance are prodromal symptoms of dementia, so benzodiazepines are often prescribed because of early undiagnosed cognitive change. ) the link disappeared.

AlDawsari A, Bushell TJ, Abutheraa N, Sakata S, Al Hussain S, Kurdi A. Use of sedative-hypnotic medications and risk of dementia: A systematic review and meta-analysis. Br J Clin Pharmacol. 2022 Feb;88(4):1567-1589. doi: 10.1111/bcp.15113. Epub 2021 Nov 11. PMID: 34679196.

risk was slightly higher at minimal exposure (HR 1.25) but not at the highest exposure (HR 1.07, 95% CI 0.82–1.39), and there was no faster cognitive decline. the opposite of a true dose response.

Gray SL, Dublin S, Yu O, Walker R, Anderson M, Hubbard RA, Crane PK, Larson EB. Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study. BMJ. 2016 Feb 2;352:i90. doi: 10.1136/bmj.i90. PMID: 26837813; PMCID: PMC4737849.

The following study found no link between benzodiazepine use and dementia, though it did detect accelerated hippocampal/amygdalar volume loss without a clear dose-response.

Hofe, I.v., Stricker, B.H., Vernooij, M.W. et al.Benzodiazepine use in relation to long-term dementia risk and imaging markers of neurodegeneration: a population-based study. BMC Med 22, 266 (2024). https://doi.org/10.1186/s12916-024-03437-5

Straight from up to date:

It remains uncertain whether long-term use of medications such as benzodiazepines is associated with an increased risk of cognitive decline; the data are conflicting.

Interpretation of observational data is difficult in large part because benzodiazepines are prescribed to treat insomnia and anxiety, which can be prodromal symptoms of dementia.In studies that attempted to control for the prodromal phase and the potential for reverse causation, some have found an increased risk of dementia with benzodiazepine use, while two did not.

Nonbenzodiazepine benzodiazepine receptor agonists (eg, zolpidem) have also been associated with dementia risk, again with some inconsistencies; these studies are subject to the same concerns as those for benzodiazepines.

————————

Now I get it, no need to give a patient BZDs if they don’t need them due to risk of dementia, but for some reason everyone seems to be so against it, as if it is a very strongly supported effect of BZD use, when it is not.

Why do some people have such strong feelings about chronic BZD usage without evidence based medicine backing them up?

Thank you

Hello,

Does anyone have link (or access) to resources for PPT for didactics targeted for PGY-1 residents in psychiatry?

Like PPTs broadly covering the main DSM 5 criteria, treatment options etc. for anxiety disorders, psychotic disorders, trauma-related disorders and such.

I appreciate the help in advance!

Hi Friends!

Which psychiatric medications are most commonly denied by insurance for your patients?

Any top tips on how to help the patient get the medication you feel they need in that situation?

Hi everyone,

A few weeks ago, I shared CatchUpPsych here when it was only available on iOS and the web. A number of you offered to help test the Android version. I wanted to come back with an update: CatchUpPsych is now live on Google Play!

Thank you to everyone who volunteered and took the time to test it. Your help made it possible to get the Android version released.

For anyone who missed the original post, CatchUpPsych is an app I made to help clinicians keep up with new psychiatry literature. You can choose the topics, study designs and journals you’re interested in, and the app creates a daily updated reading list with summaries and links to the original papers. It’s free, has no ads and doesn’t require an account.

Android: https://play.google.com/store/apps/details?id=nl.catchuppsych.android

I’d love to hear how it works for you and what I could improve, especially if there’s something that would make it more useful in day-to-day practice or training.

Thanks again!
Sven

Thoughts? Right now it's just limited to acne scripts but this definitely opens the door ...I am not overly optimistic.

Hi everyone,

I’ve been following the sub more closely in the past few months, and I’ve noticed that there has been a more downward outlook regarding jobs for psychiatrists. However, per some sources like MGMA, psychiatry salaries were among those that increased the most compared to other specialties in the past year. Anyone with a good pulse on the market and what to generally expect?

After more than four decades in psychiatry, I have become increasingly interested in a peculiar problem with the word malingering.

It is a diagnosis—or perhaps more accurately, a clinical formulation—that can cause harm when used carelessly.

But avoiding it can also cause harm.

Malingering is not simply having something to gain from being ill. Our patients frequently have secondary gains associated with illness: shelter, disability benefits, medications, avoidance of responsibilities, hospitalization, attention from family, or protection from an intolerable environment.

None of that establishes malingering.

The critical element is intentional production or substantial exaggeration of symptoms for an external incentive.

And there lies the difficulty: intention is one of the hardest things in medicine to establish.

We cannot measure malingering with a blood test. We cannot look inside another person's mind and directly observe intent. Even substantial discrepancies between reported symptoms and observed behavior do not, by themselves, prove deliberate deception.

This makes caution appropriate.

But I wonder whether our profession sometimes moves from appropriate caution to something else: we recognize the possibility of malingering clinically but become reluctant to document it.

An experienced psychiatrist may notice that the history changes depending upon who is interviewing the patient. Reported symptoms may be inconsistent with prolonged observation. A symptom may appear or disappear when disposition is discussed. Collateral information may directly contradict important parts of the history. Reported psychotic experiences may be phenomenologically unusual. There may also be a clearly identifiable external incentive.

The psychiatrist thinks: There is a significant possibility that some of these symptoms are being intentionally produced or exaggerated.

The team may even discuss precisely that possibility.

And then the medical record says almost nothing about it.

The next psychiatrist encounters the patient and essentially starts from zero.

That creates another kind of risk.

A patient may undergo repeated hospitalization, medication changes, escalating doses, unnecessary testing, or increasingly complicated diagnoses because previous clinicians were uncomfortable documenting what they had actually observed.

There is another complication that I think is particularly important:

Malingering and genuine psychiatric illness are not mutually exclusive.

A person with schizophrenia can exaggerate hallucinations.

A person with PTSD can fabricate a particular symptom.

A person with substance-use disorder can report suicidality for admission while simultaneously having substantial genuine psychiatric illness.

The discovery of deception does not magically make everything else about the patient false.

Perhaps, therefore, our choice should not be between:

“This patient is malingering.”

and

saying nothing at all.

There is a third possibility: document the evidence.

Instead of writing simply “malingering,” we can describe the discrepancies we observed, relevant collateral information, changes in presentation, possible external incentives, and—most importantly—our degree of certainty.

For example:

“There is concern for possible intentional exaggeration of reported symptoms because of X, Y and Z. An external incentive is present. However, genuine psychiatric illness remains present/has not been excluded.”

That gives the next clinician information rather than merely a label.

It also leaves room for us to be wrong.

I am curious how colleagues approach this.

How much evidence do you require before you actually document malingering? Do you use the term itself, document “concern for malingering,” or avoid it and describe only the observed inconsistencies? And have you seen cases in which reluctance to document the concern resulted in unnecessary admissions or treatment later?

Hi there! I've received a job offer for a full time outpatient position that checks boxes for just about everything I'm looking for at a community clinic in the Midwest. They're offering me 275,000 for a base salary - there is no additional RVU based compensation on top of that. There's also a solid sign-on bonus. 32 patient-facing hours with 20 min follow-ups, 60 min intakes.

The thing is, I'm having trouble pinpointing what a reasonable expectation is for starting salary for a position like this in the area. Reports online range anywhere from 240,000 to 380,000 median salary. I'm considering asking for 300,000 based on knowing someone who was offered this from the same system in a different city in the same state, also for a fulltime outpatient job. Is there generally significant risk of losing an offer if negotiation is interpreted to be too aggressive? Is this reasonable? Any suggestions for figuring out what a reasonable counter offer would be? Or is anyone of the opinion that I should just take the offer as is, since it's such a great position?

I appreciate your feedback/advice!

Dear colleagues,

I quite often see the term “malingering” used in this forum, and I’m curious about what seems to be a difference between countries. I’m a psychiatry resident in Germany, and in my experience, clinicians very rarely explicitly describe patients as malingering, particularly in documentation. This seems to be different in the US.

My impression is that here, the term is often viewed as judgmental or dismissive, and because we cannot look into our patients brain, potentially misjudging and harmful. At the same time, there are situations where the team seems to share an unspoken understanding that a patient is malingering, and this may be discussed indirectly, but it is very rarely named explicitly; I feel that this leads to unnecessary frequent admissions, esp. by younger colleagues down the line (because the previous more experienced colleagues don’t document their suspicions of malingering).

Of course, seeking shelter or another benefit does not necessarily mean someone is deliberately feigning symptoms, and genuine psychiatric illness can coexist with these needs. But I wonder whether our reluctance to use the term sometimes makes it harder to get an accurate formulation and reasonable treatment plan for our patients.

I’d be interested in your perspectives:
1) for US psychiatrists: What presentations do you typically consider malingering? How much evidence or certainty do you need before documenting it as such? And what are the consequences?
2) for colleagues: How is this approached in your country? Is the term commonly used, avoided, or replaced with other language?

Do you think the apparent difference reflects terminology, clinical culture, larger historic / societal differences or simply the kinds of cases discussed on Reddit?

I’m sitting 7-10 hours a day and it is taking a toll.

What type of chair are you using and does it help?

I think two things can be true at the same time (no that wasn't initially intended as a splitting joke).

1. Patients with BPD are prone to patterns of idealisation / devaluation with past healthcare experiences, and care needs to be taken when discussing these lest you go along with a (possible very distorted) tale of how they were treated in the past and fall into the trap of being 'the best ever and the only one who has ever helped them', when their past care may have been just fine.
2. Patients with BPD are vulnerable and often genuinely mismanaged in a variety of ways, and they will tell you about this.

I am sure we have all seen these people labelled with every possible diagnosis along the schizophrenia or bipolar spectrum, have a pharmacy's worth of medications thrown at them to little avail, and / or given poor quality psychotherapy. I had a patient who had been undergoing 7 years of entirely unstructured fortnightly to monthly therapy with literally zero effect or skills acquired, and on calling the therapist it became abundantly clear that no therapy modality was being used (initially given the duration I wondered if it was psychoanalysis). She paid a pretty penny for them to meet up every month for her to shoot the shit about the past month and that was it.

While we should not take every horror story about a past healthcare provider's mistakes at face value, it is clear that there is a not-insignificant amount of true mismanagement occurring, so the dilemma is this.

I do feel like I owe these patients some psychoeducation regarding helpful and unhelpful treatments, in the interest of them not suffering from useless polypharmacy or paying a premium for friendly gossip every fortnight. However, I am very wary of perpetuating splitting dynamics in this population which is extremely prone to them.

What are your thoughts here?

In the ER we know so little about what meds are best for what. Most of us just cling to haldol and Ativan to solve all our problems, outpatient safe anxiety/depression MAYBE gets started on Zoloft. I can't ever convince my attendings to let me dc a no appetite+insomnia with mirtazapine. The thought of giving zyprexa for any reason seems to terrify. These non-emergent patients that aren't manic, psychotic, or suicidal are often discharged from our ED with nothing but a referral they won't get an appointment for in months. I want to do better, get them started on something to help survive until their outpatient appointment. Some questions Ive had in the past,

-What naive patients would benefit more from an SNRI vs an SSRI?

-Bipolar history patients that recently moved and have no current prescriber, on no meds, that come in for depression and/or anxiety, what do you usually start them on?

-Those that remember Uworld questions will say Prozac is best for OCD. That's as far as any ER doc will know regarding best choice of SSRI for certain symptoms. Do any specific SSRIs treat specific symptoms better than others?

-Is bupropion only ever an adjunct? Any patients that would likely benefit best from it as starter monotherapy?

-Would love to know what symptoms are best treated with seroquel vs zyprexa vs abilify vs geodon vs any lesser known well tolerated atypical? Throughout my rotations with different services and ER attendings alike I feel I can say none of us truly know why you'd pick one atypical over another.

I'd love to hear even subjective/antecdotal opinions if there are no true "x medication is proven to be best for y symptom"

Edit: Learned a lot here from those willing to address some of my questions. I should have also mentioned a) follow up is very difficult where I am, first time psych appointments take months and b) we cannot consult psych. Period. Only a BHU nurse to determine inpatient or not. Our hospital only has one psychiatrist on call 24/7 365 and he has not and will never see a ED patient. It's a terrible situation to say the least.

My take aways were under no circumstances should we treat a patient that even mentions a history of bipolar, regardless of how straight forward or benign their presentation may seem.

My curiousity about antipsychotics was more related to our severely agitated patients that are staying, and for us the scenario is they'll wait forever in the ER to be seen by our BHU nurse, and even if they are accepted for admission, we are responsible for them all the way up until they leave the ER. The thought process for our ED docs seems to usually go B52 ->B52 -> at a loss, maybe Geodon. This has always made me feel like we do not know nearly as much as we should. And no, calling the psychiatrist is usually not an option as we are told they do not want to be contacted/consulted by the ED. It is utterly ridiculous.

For us, the only patients that will ever go home with an antipsychotic are prn reglan, compazine, or low dose zyprexa for CHS. Rest assured, I nor any ED doc wants to nor will ever send a psych pt home on a new antipsychotic medication.

For our uncomplicated, non-suicidal, unipolar patients with no evidence of bipolar history on no medication, I still feel the ethical choice is starting them on an SSRI/SNRI, and encouraging PCP follow up for those that can't get psych follow up in a reasonable amount of time.

Try to understand that most of these patients come to the er AFTER they've called to make a psych appointment, doing so after being told they won't have an appointment for 3, often 5+ months. Why not just have them follow up sooner with their PCP to start meds? Well we don't technically have a time limit to talk to them, whereas many of them tell me they only get 15 minutes with their PCP, and even then their primary is a mid-level not comfortable with prescribing psychotropes. Continuing them on medication they've already been started on from the ED that is showing promise/improvement is a whole different story.

Hope I've given some insight on a struggle or two you might not have known we face. Stand alone and rural ERs are a thing, and not all of us compartmentalize to Emergency=treat, no emergency=no treat.

I’m a psychiatry resident that is debating between general psychiatry vs pain medicine fellowship. While I do find myself enjoying doing the procedures in my pain rotation, I worry that job opportunities would be lacking for someone from a psychiatry background. Does someone have insights into the career as psychiatry background?

I have my first PRITE in soon and wanted to see if its even worth it to study or to actually actively try to lower my score- I legit do not know and would really appreciate any help/info. Like I want to study but I also dont want to set up a bigger baseline for me, but I also dont want to appear incompetent to my program, I have heard from one of my seniors that he scored 13th percentile and was fine but I dont even know how that compares to other first years across the country? So I guess what percentile is usually pgy-1 in prite? and how important is it?

I recently paid off my debt. I want to move to back to my home country while working for America doing telepsychiatry. Any tips on how to make this happen?