Priorities

The annual meeting of the Association of Medicine and Psychiatry (AMP) is being held in Chicago this weekend. This meeting is an excellent opportunity for medical students to network with dually-trained physicians and program directors, current med/psych residents, as well as the handful of other medical students applying to combined training programs. I had been looking forward to this meeting ever since I discovered med/psych earlier this year, but it unfortunately falls on the same weekend as my grandmother's 91st birthday.

The decision wasn't difficult, to skip the meeting and celebrate my grandmother's birthday. How many birthdays and other big family events have I already missed because of medical school, and how many more will I miss during residency? I am still disappointed to forgo all the networking opportunities, especially heading into interview season. But the program director at Davis offered me some reassurance when I told him why I couldn't attend: "There will be meetings every year. Go spend time with your family."

Well-deserved vacation

I finished the Davis externship, and now I'm on my first real vacation since Winter break in December 2011. The two weeks I spent at home last month don't count because I was studying for Step 2. So here I am back at home: nothing to study, no patients to care for, no responsibilities except to relax. It feels great.

Davis: End of the externship

My externship with the Davis combined medicine/psychiatry program ended today. I left the clinic this afternoon with a sense of satisfaction that the experience was all-around positive and that I received encouraging feedback from everyone. I'm sad to be leaving, and I'm eager to return to Davis for the interview; this speaks volumes about my gut-level feeling about the program.

I had two goals when I started this externship. First, I wanted to figure out whether combined medicine/psychiatry is right for me, or whether I might be better served by a pure medicine or pure psychiatry program. Second, I wanted to get a better feel for the UC Davis program, in particular: the leadership, the residents, the strength of the training, and the general environment of Sacramento.

On the first goal:

I am much more certain now than when I started this rotation that I want combined training. I could only feel comfortable coming to this conclusion after gaining first-hand experience in an environment that combines medicine and psychiatry to provide integrated patient care. This rotation leaned heavily toward the psychiatry end of the spectrum, much to my initial disappointment. But this limitation to my experience here at UC Davis provided a contrast that helped me appreciate the satisfaction I feel from treating patients' medical and psychiatric needs together.

Over these past four weeks, I learned why much of my clinic experience was straight psychiatry: MediCal reimbursement rules prevent billing for medical and psychiatric services in one visit. In fact, one of my last patients of this rotation lamented that she would soon have to find a new primary care provider for her medical needs because her insurance was switching over to MediCal. This is a woman with COPD, congestive heart failure, diabetes, and bipolar disorder, all of which my dually-trained attending has been managing well. She would be ill-served being forced to find a new primary care provider who just treats her medical needs. My attending says that changes to MediCal reimbursement rules are in the works to address this problem. This is a poignant lesson, though, of the types of struggles that I will likely face in choosing the combined medicine/psychiatry path.

On the second goal:

Over and over again, I was struck by how friendly and happy people are here at UC Davis. I'm left with the feeling that I would enjoy working with these residents and attendings, an extremely important feeling considering that these would be my colleagues for the next five years. Both the medicine and psychiatry programs, as well as the combined training program, are very strong. And Sacramento itself was a pleasant surprise. It's a small city with not too much going on, which suits my purposes just fine for residency. The heat was not unbearable as I was expecting. And it's close by to many attractions (e.g. San Francisco, Lake Tahoe, the Redwoods). My attending says that Sacramento is a better place to live than visit. I agree.



So, with everything said and done, my mind wanders back to about four years ago when I was visiting different medical schools. I remember walking around Colorado's medical school campus, taking everything in, thinking, "I could see myself happy here." And it turns out that I was. I get that same feeling from Davis. This is a nice starting point to have heading into interview season.

First residency interview offer!

I got my first residency interview invitation this morning! So exciting! The whole thing feels a lot more real, now.

Late Update: My first interview offer was to Iowa's combined medicine/psychiatry program. Exciting!

Residency application: Submitted!

Today is a big day for fourth-year medical students all over the country, the day when we can finally apply for residency programs. This is done through ERAS, the Electronic Residency Application System that aggregates all application materials. The whole process is much simpler than applying for medical school. There are only three parts to ERAS that medical students have any control over: 1) the personal statement, 2) the curriculum vitae, and 3) letters of recommendation.

I did my fair share of freaking out about the personal statement. My perfectionist traits shine brightly when writing an essay that's meant to convey most of who I am and the kind of doctor I want to become, all in less than a page. But beyond that, I've had a surprisingly zen attitude about this new round of applications. It doesn't do to obsess about something that can't be changed. For all the nit-picking over my application this last week, the substance of my application has been settled for quite some time.

Perhaps that's why clicking the "Submit" button this afternoon felt anticlimactic. I celebrated, regardless. How exciting to think about all those program directors out there reading through my application! Nerve-wracking to wait for the interview offers? Yes. But I'm confident in my application and am looking forward to this next step in the long slog of becoming a doctor.

Be a sponge

I had lunch with the med/psych program director for my midpoint evaluation. His feedback was different than any of the feedback I have gotten during other midpoint evaluations, which more often than not are formalities and not all that helpful. "I want you to take a step back," he said. "I want you to absorb everything that's going on around you. Be a sponge."

This advice was especially interesting to me because it echoes something that a close friend told me as I headed off to medical school: "Be a medical anthropologist. Look at what works and what doesn't work in the medical system and think about how you would do it differently." So, throughout medical school, I have been purposefully doing just that. Here at UC Davis, taking a step back and observing as much as possible of my surroundings and the people around me, that is all the more important as I am trying to figure out whether this is the right residency program for me.

Face time with med/psych residents

Last week, the chief resident took me and a few other med/psych residents out for my first recruitment dinner of the interview season. It's a great opportunity to get to know the people who I may be working with closely over the next five years. Do I like them? Would they be easy to work with? No doubt they are asking those same questions about me. This dinner was all the more important, for all of us. Because I have mostly been working with dually-trained attendings and psychiatry interns, I haven't had the opportunity to get to know my potential future colleagues.

Recruitment dinners in general have an interesting dynamic. On the one hand, it's a social event, and everyone should be having fun. I don't want to come across as boring or rigid or anything else negative, but I also don't want to have too much fun. I've heard many stories from current interns about applicants who drink too much alcohol during these recruitment dinners and end up making asses of themselves. Why anyone would do such a thing with so much in the balance is beyond me. Regardless, I did genuinely enjoy dinner and chatting with the med/psych residents.

Then, this weekend, I took a day trip to San Francisco with one of the med/psych interns and a couple of her friends. The whole day was very relaxed and a ton of fun, a showcase of what my days off could be like if I end up at UC Davis.

Answering personal questions from patients

I was interviewing a depressed patient with my attending in the room, watching. I asked my patient if she had any thoughts of death or dying, and she said yes. "Well what of it? Haven't you had those thoughts?" This direct personal question took me aback. I faltered, then I answered her question. I knew right away that she was trying to rationalize her own morbid thoughts by normalizing them. See, you think about death, too, so my thoughts of death are normal.

Then she turned to my attending and asked him the same question, but he handled it completely differently. He sat back relaxed in his chair, looked down at the floor briefly then right back up at the patient meeting her eyes, he smirked slightly, then he said, "You know, I think it's really interesting you asked me that." His voice was saturated with sincere curiosity. "Why is it do you think you asked me that?"

I was in awe. How deftly he had flipped her question right back to her and incorporated the very fact that she had asked that question into an exploration of her depressive symptoms! The patient went right along with the flow of the conversation. My attending never did end up answering her question.

I talked with my attending about it afterward. "You're going to be asked a lot of personal questions throughout your career: Are you single? Do you have children? How much money do you make? There's always something behind the question, and it's your job to figure out what it is." He went on to say that a very real power differential exists in the clinical interview. It's not unfair; that's just the way it is. If I ever feel like a patient is interviewing me, that should give me reason to pause and wonder, Why? From there, I should let my own curiosity guide my response.

This lesson made quite an impression on me, and it gave me an important tool to use in future clinical interviews.

UC Davis: Summary of the first week

My first week on medicine/psychiatry was a good one.

I am spending most of my time at the Sacramento County Primary Care Center (PCC), which mostly caters to an indigent patient population. There is a separate Integrated Behavioral Health clinic with a set of three dually trained physicians who supervise me and another fourth year student. She attends UC Davis and is applying for internal medicine residency. I am also spending a few mornings per week at a pain clinic staffed by the Medicine/Psychiatry program director.

Everyone with whom I have interacted is very nice and welcoming... and just as important, they all seem happy.

But so far, I haven't met any Medicine/Psychiatry residents. The one resident at PCC is a psychiatry intern and so is not a good person to talk with about dual training. The Medicine/Psychiatry chief resident, though, has been in close contact with me to make sure that I am having a good experience. I am looking forward to interacting more with the Medicine/Psychiatry residents. Beyond just asking them questions, I want to get a better feel for how happy they are in the program, with their training experience.


Regarding what I have discovered about the actual practice of combined medicine and psychiatry, I was surprised that the vast majority of patients who I saw at PCC were there only for management of chronic psychiatric conditions without addressing any of their medical problems. My attending says that this is mostly due to insurance reasons, because neither Medi-Cal nor Medicaid reimburse fully for office visits that address both psychiatric and medical problems. That is concerning to me but not altogether unexpected given some of the criticisms I have heard from various people about combined training programs.

I have been exposed to a lot more of mixed medicine and psychiatry in the pain clinic, where patients' chronic pain issues often stem from both physical and mental causes.

There is still so much to experience during this externship. Next week I will also see patients on the psychosomatic medicine inpatient unit.