How I decided on a combined medicine/psychiatry residency

The third-year medical student has three jobs: 1) To learn how to take a good history and do a good physical exam; 2) To learn how to present patients, both written and orally; and 3) To figure out what field of medicine to specialize in. I found this last job to be the most difficult.

Pre-med and the pre-clinical years

To provide some context, I came into medical school having worked for four years researching the neurobiology of eating disorders. I very much enjoyed and valued my pre-med experience in psychiatry, but I also wanted to keep an open mind when it came to other possible specialties and career paths. This translated into me looking practically everywhere except at psychiatry.

During the first two years, when I was just in the classroom and didn't yet have any practical clinical experience, I investigated various specialties: emergency medicine, neurology, neuroradiology, interventional radiology, surgery.

The third year

Over this past year, as I've gained clinical experience in various fields, I have tried to be purposeful and methodical about how I evaluate each specialty as a possible career. This process of elimination is pretty typical for third-year medical students. I had all but ruled out many possible specialties before third year, but I also tried to keep an open mind. I liked most of my clinical rotations and seriously thought about careers in those specialties.

• I was very interested in emergency medicine, ever since my first year, but eventually nixed it because I want to have continuity of care and to treat the whole patient rather than one acute problem at a time.
• I seriously considered surgery but reluctantly decided against it because of lifestyle issues.
• I got excited about anesthesiology but vetoed it because I want more significant patient interaction.
• I loved pediatric neurology and only recently crossed it off the list because I decided that I don't like general pediatrics enough to do the training. Also, even though I figured out that I could probably handle the sad stories and poor outcomes, I decided that it's just not what I want.

Then there were my internal medicine and psychiatry clerkships. I loved them both.

Internal Medicine

Last Summer, on a warm evening after a long day at the hospital, I was lying underneath a tree in the park talking on the phone with my sister. She asked me how I was liking internal medicine, and my immediate response was that I love the puzzle. I have a patient with a given set of symptoms and a unique history, and based on both of those, I have to decide on what labs and studies to order to figure out what is causing that particular constellation of symptoms and how to treat it. I told my sister that the inpatient setting gives me more time to sit down and really talk with my patients, as well as to thoroughly think through the differential diagnosis. I like internal medicine because it involves both thinking and doing.

Looking back, my most memorable and favorite medicine patients all had psychiatric comorbidities. After awhile, my medicine residents were giving me the "difficult" psychiatric patients because they knew that I was drawn to those patients.

Psychiatry

Then there was my psychiatry clerkship. I looked forward to it with excitement but also some trepidation. What if I liked it? Could I really become a psychiatrist? I worried about that because there truly is a distinction between the practice of medicine and the practice of psychiatry.

It turned out that I did very much like psychiatry. I found that reading for psychiatry was easy because I was so interested in the subject matter... I spent much longer talking with my patients than I needed to... I wrote much longer notes than I should have because I had so much to say and was so fascinated by my patients... I jumped into psychotherapy with some of my patients even though that's way beyond the scope of a third-year medical student....

Discovering med/psych

Liking psychiatry so much posed a problem because I held a mental block against it. Much of that mental block likely came from my desire to practice medicine, not solely treat mental illness. About midway through my psychiatry clerkship, responding to what I recognized as ambiguous reservations against psychiatry, I started researching various psychiatry fellowships. That's when I "discovered" combined medicine and psychiatry residency training programs.

I hadn't even known that such programs existed. Thinking back to my internal medicine clerkship and how much I enjoyed it, I immediately started daydreaming about what I could do with training in both internal medicine and psychiatry. I stayed up way too late that night researching med/psych programs.


The more I thought about med/psych as a training path, the more excited I got. I could continue my work in anorexia and bulimia or focus on binge eating and obesity. I could do geriatrics. I could do palliative care. I could do international and refugee medicine. So many possibilities! I'm the type of person who likes to keep my options open. Med/psych training could give me the best of both worlds; I could have my cake and eat it too!

I realized, though, that I was getting all excited about med/psych with a very limited amount of information, only what was available on the various program websites and the Association of Medicine and Psychiatry website. I needed more information, better information.

Talking with med/psych program directors

A few of the med/psych programs stood out to me, both because of the quality of the integrated curriculum and the general feel of the institutional culture. The directors of these programs wrote open letters describing med/psych, promoting their respective program, and inviting those interested in med/psych to contact them with any questions. Recognizing that contacting these program directors could potentially be self-defeating, I decided that it was worth the risk because I needed to talk with someone - multiple people - in the med/psych world.

I e-mailed three program directors and actually talked on the phone with two of them. I was blown away by how open and friendly and helpful they were, that they would set aside time from their lives to talk with me about med/psych. They answered my myriad questions, settling two major concerns about pursuing both medicine and psychiatry.

• Concern #1: You'd just end up choosing one or the other eventually, so why waste time training for both? Response: We actively encourage our graduates to establish a practice that incorporates both medicine and psychiatry, and most of them do find a niche for themselves. Even if your practice ends up being predominantly medicine or predominantly psychiatry, you will draw upon your training in the other and be a better doctor for it. I doubt that you'll ever regret your training. Both program directors said essentially the same thing in different ways, and I agree with them.
• Concern #2: A combined program would leave you less well trained in both medicine and psychiatry than if you completed a pure residency in one or the other. Response: Our pass rate is 100% for both the medicine and psychiatry boards. Our graduates report feeling very well prepared for both boards and for the responsibilities of being an attending physician. That speaks for itself.

Talking with current med/psych residents

I asked those program directors to put me in touch with current med/psych residents. Being in the middle of this stressful decision-making process, I wanted to talk with someone whose memories of that process are more fresh in the mind. How did you discover med/psych? Did you seriously consider other specialties, or medicine alone, or psychiatry alone? Why did you end up deciding on med/psych? Did you know what you wanted to do with med/psych before residency? I felt that these questions needed to be addressed now as opposed to during an externship or on the interview trail.

One resident answered that he decided on med/psych simply because he wanted to treat the whole patient, not just a set of symptoms. This struck a chord with me. I thought back to my medicine rotation and remembered how frustrated I felt when the psychiatry consult service swooped in to evaluate patients with psychiatric concerns: I wanted to be a part of that aspect of my patient's care. I also thought back to my psychiatry rotation and my frustrations when the smallest medical issue was outsourced to internal medicine. I want to treat the whole patient, too.

Enthusiasm flowed freely from every resident I talked with. Everyone was happy. Everyone was 100% satisfied with their career choice. Everyone would do it over again the same way in a heartbeat. And talking with each successive resident, that enthusiasm rubbed off on me. The vague intuitive sense of rightness I originally felt when I discovered med/psych crystallized into certainty that a combined medicine and psychiatry training is perfect for me.

Trying on med/psych for size

I can't count how many times I've been asked, "What are you going into?" or "Do you know yet what you're specializing in?" It's especially bad toward the end of third-year and even worse when I start a new rotation. So pediatrics and OB/Gyn have offered me numerous opportunities to see how med/psych fits. Rather than hedging, I started answering decisively, "I am going to do a combined medicine and psychiatry residency program."

Reactions have been interesting, ranging from "Oh, what a waste of talent," to probing my reasons for choosing a less traditional training path, to "Wow, that's awesome!" The negative reactions didn't get me down, and the positive ones only stoked my excitement for med/psych further. These self-observations are incredibly helpful in making the final leap to a decision that without overstatement will profoundly shape the rest of my life.

So I've taken that leap. I will apply to combined medicine/psychiatry residency programs.

From clinic to the operating room

A new patient was referred to the gynecology clinic from an outside community clinic that serves a low-income population. She was at the end of her rope dealing with symptoms from a condition that she allowed to progress for so long because she couldn't afford to fix it.

I was working with the chief resident, who is essentially almost a "real" doctor; even she was taken aback. "I'm going to go talk with the supervising doctor, and we'll see what we can do for you." The attending was equally impressed with the patient's history and physical exam and scheduled her for surgery the very next day.

My resident invited me to watch the surgery. "It'll give you a chance to follow a patient from start to finish." Thank you so much! This kind of continuity, as a medical student, is not the norm. I had to play hookie from afternoon clinic (with the chief's permission) in order to see my patient's surgery.

During the first two weeks of this clerkship, I saw many surgeries on women whom I had never met and never examined. The only history I knew of them is what I read in their chart and what the resident told me beforehand. Occasionally, I'd have a few minutes to chat with these patients immediately before surgery. But the whole experience felt disjointed.

That's why I'm incredibly grateful to have experienced the kind of continuity of care, from clinic to surgery, that the residents and attendings enjoy. The attending even stepped back allowing my resident to operate and leaving me to first-assist! And she invited me to accompany her to talk with the patient's family afterward! The experience felt complete.

I think more effort should be made to give medical students this kind of patient continuity. In terms of teaching and learning, I personally find that such continuity is especially effective: I will never forget this patient.

Urogynecology and gynecologic oncology

I finished my week of urogynecology and gynecologic oncology (UroGyn/GynOnc) having seen a lot of pelvic organ prolapse and transvaginal taping for stress incontinence. But I didn't see much pathology. In fact I didn't see any. No ovarian cancer, no uterine or endometrial cancer, no cervical cancer, no endometriosis. I'm disappointed, but that's the luck of the draw.

Up next: A week of gynecology clinic, then on to obstetrics (a.k.a. "baby-catching").

Anesthesiology reunion

Returning to St. Joe's for OB/Gyn has been fun because I'm seeing a bunch of people who I worked with several months ago during my surgery clerkship. One of those people is an anesthesiologist who got me so excited about anesthesiology that I seriously considered it as a possible career.

He happened to be the anesthesiologist working one of my gynecology cases, recently. We exchanged pleasantries, caught up a bit, then he asked, "So, are you going to intubate this patient for me?" This caught the attention of my resident who practically shouted, "What? You never let me intubate anyone!" My anesthesiologist friend replied, "Yeah, but I've worked with him before, and I trust him."

This was all just playful banter. My resident wasn't really upset, but the pressure was on: I hadn't intubated anyone for more than 3 months! I had a little bit of difficulty visualizing the cords, but I got them finally and successfully intubated the patient on the first try.

OB/Gyn site and schedule

I had such a good time on my surgery rotation at Exempla St. Joe's that I decided to do my OB/Gyn rotation here, too. Since the site assignments for the OB/Gyn rotation are given on a first-come-first-serve basis, I got lucky with getting my first choice. ESJ is a very popular site among medical students because it has a reputation of very nice attendings and residents. So far, its reputation has borne out to be true.

The six-week OB/Gyn block is divided into weeks on different services. My schedule:

• Week 1: Benign gynecology. Lots of surgeries. Get in early enough to pre-round on 1-3 patients and have my notes written and shared with the resident by 6:45 am. Usually leave by 5:00-6:00 pm.
• Week 2: Gynecologic oncology and urogynecology. Similar to benign gynecology but with sicker patients.
• Week 3: Gynecology clinic. Show up for educational rounds at 7:00 am and leave after the last patient, around 4:30-5:00 pm. Have to wear professional clothes, not scrubs.
• Week 4: Labor and delivery nights. Shift work from 5:00 pm to 8:30 am, starting Sunday night.
• Week 5: Obstetrics clinic. Essentially the same schedule as gynecology clinic.
• Week 6: Labor and delivery days. Not sure about this schedule, yet.

I definitely wasn't expecting that I would have most of my weekends free. I'll have to come in on the Sunday evening of my L&D nights week, and the residents may ask me to round on patients over the weekend if my patients happen to provide a particularly good learning opportunity.

Overall, I think OB/Gyn will be a good experience.

The week of hysterectomies

I saw several hysterectomies this week on the gynecology service, each a different flavor. A resident pointed me in the direction of a wonderful resource, the Atlas of Pelvic Surgery, which describes specific surgeries step-by-step with accompanying pictures. Reviewing each procedure ahead of time helped me better understand what was happening in the operating room.


One hysterectomy was a total vaginal hysterectomy, which delivers the uterus through the vagina. This patient had a prolapsed uterus, which basically means that the tissues holding the uterus in place were failing causing the uterus to sink down lower into the pelvis and out the vagina.


Another was a total abdominal hysterectomy, a procedure that removes the uterus through an incision in the lower abdomen. The abdominal approach was chosen, versus a transvaginal approach, because the uterus was burdened by several fibroids, one of them the size of a softball. Attempting to deliver such a large uterus through the vagina wouldn't have been smart.

The most interesting hysterectomy I saw was a laparoscopy assisted vaginal hysterectomy that was converted to an open procedure because of uncontrolled bleeding from the uterine arteries, which were difficult to clamp laparoscopically because of abnormal anatomy.

This turned into a true emergency. The gynecological surgeon never lost his calm, but he also started moving much more quickly than surgeons usually move. Less than 30 seconds after he called out "We're converting to open!" he and the resident made an incision across the lower abdomen and were literally tearing apart the subcutaneous tissue to gain access to the abdominal cavity. The bleeding was stopped, and the rest of the surgery went without further complications.

The attending asked me afterward, "What's the first thing you do in a Code situation?" My answer: check for airway, breathing, and circulation. Not entirely incorrect, but his answer was much more to the point: Take your own pulse.

Seeing three different surgical approaches toward the same end goal, removal of the uterus, was very helpful in terms of understanding the female pelvic anatomy. I also have a higher appreciation for how anatomic variability, both normal and abnormal, determines the course a surgery.

OB/Gyn orientation

The OB/Gyn clerkship orientation included some very practical instruction. What I found to be most useful out of the two-day orientation was a refresher course on how to do the breast and pelvic exams. We all learned these sensitive exams for the first time at the end of our second year with formal instruction from standardized patient-actors who taught the exams using their own bodies. But that was almost a year ago. Over the course of my third-year, I've had the multiple opportunities to perform breast and pelvic exams, but they were few and far between, not enough to keep those clinical skills sharp. Apparently, including this refresher session during orientation is a relatively new development and was done in response to student feedback. I'm grateful! I'm especially grateful after talking to some medical student friends at other institutions who were never taught how to perform a pelvic exam before seeing a real gynecological patient.


We also had a session with a medical mannequin in active labor. In my humble opinion, this is a much better way of preparing medical students for L&D than just throwing them in the deep end with a real patient in labor. Although this mannequin is capable of simulating labor and delivery to striking detail, the purpose of this session was really just to familiarize us with the basic steps of the birthing process. As happy as I am that I got this simulation experience, I have a feeling that it will be absolutely nothing like the real deal.

OB/Gyn prejudices

A friend recently asked me, "Are you looking forward to or dreading your OB/Gyn rotation?" I don't think either term adequately describes how I feel about this clerkship.

OB/Gyn is the one specialty that I pretty much knew 100% I didn't want to go into even before third year. But, I recognize that my OB/Gyn experience will be very educational and an opportunity that I likely won't have during the rest of my career. So I am definitely looking forward to the experience of OB/Gyn, especially the OB part that involves delivering babies. That being said, I'm also looking forward to being done with the clerkship.

Do I dread OB/Gyn? I have to admit that there are certain aspects of OB/Gyn that are slightly anxiety-provoking. I've heard disconcerting stories about some OB/Gyn residents and attendings. I'm wondering how I'll actually be received by patients, as a male medical student. I'll also be straightforward and say that I'm not looking forward to doing pelvic exam after pelvic exam for the next six weeks. But, like everything else in medical school, it's something that I just do, putting in my best effort and with a good attitude, even if I don't want to make a career out of OB/Gyn.

It'll be interesting to see how my opinions of OB/Gyn at the end of the clerkship compare to my prejudices of it now.

Pushing back against the war on vaccines

It was bound to happen eventually on my pediatrics rotation: coming across parents who for one reason or another refuse to vaccinate their children.

The most recent anti-vaccination movement stems from a 1998 Lancet article that ostensibly showed a link between the measles, mumps and rubella (MMR) vaccine and a so-called "bowel-brain syndrome" that involves non-specific bowel inflammation and a regressive type of autism. Vaccination opponents seized upon this article as legitimization of their views while the medical community collectively gasped.

Much has been written about the methodological and ethical problems with the study; a lot of time and energy was invested into reproducing or disproving the results of this study. Ultimately, though, it was an investigative journalist who showed that the author of MMR-autism study had allegedly cooked the data for financial gain (How the case against the MMR vaccine was fixed, British Medical Journal, 5 JAN 2011). This led to a formal investigation, public censure of the primary author, and the paper's retraction more than a decade after its publication.

But not before the damage was done. The authors of this paper used a respected and authoritative medical journal as a platform to spread what appear to be lies, the result of which was millions of parents questioning whether they should give their children the MMR vaccine - or any vaccine - for fear that it will cause autism. Many parents who had the misfortune of learning that their child has autism, desperately searching for reason, have stumbled upon the falsehoods spread by this article that seemingly explain the unexplainable.

Vaccinating children: Keeping the dialogue open

This is a dilemma faced by pediatricians worldwide, dealing with parents who are skeptical of vaccines or who flat-out refuse to vaccinate their children.

One such parent stood out over the course of my pediatrics rotation. She is the mother of an autistic child who hadn't received any vaccinations since 18 months and was coming in for a well-child visit. My preceptor warned me that this child's immunizations were not up to date and that the mother would likely continue to refuse all vaccinations. "What's your approach to such a parent?" I asked because some pediatricians (including one provider who I worked with previously) just have the parent sign a form without any discussion. "I always keep the patient in my practice, and I try to keep the dialogue open," she replied.

So, when it came time to talk about immunizations, I jumped right in:

"It seems that he's not up to date on his immunizations. Which shots do you want him to get today?"

Mom replied: "I don't want him to get any shots."

Feigned surprise: "Why not?"

"I just don't. He doesn't need them."

"Why do you think he doesn't need immunizations?"

"He just doesn't. He's not going to get sick."

My preceptor interjected: "Do you think there's a link between vaccinations and your son's autism? The only scientific publication that suggested a link was--"

"No, I don't believe that."

I sat back and thought for a few moments, perhaps slightly theatrically. "Tell me, what's your understanding of the diseases that these vaccinations protect against?" This question seemed to catch Mom off guard. The door was cracked slightly open, so I took the opportunity to educate Mom about hepatitis A and measles and mumps and rubella and chicken pox....

Oops, tactical error. Mom jumped on the chicken pox: "See, why does my son have to get a shot for chicken pox? I had it when I was a kid, and I did just fine!"

My preceptor rescued me: "Before we started vaccinating against chicken pox, a few hundred kids died from it every year. Percentage-wise, that might not sound like a lot, but if it's your kid who doesn't come home from the hospital because of chicken pox, then those chances are 100% for you. Did you have any complications from your chicken pox?"

"Yes, I was hospitalized for two days."

Then my preceptor closed the deal: "Well, it would be a horrible shame if your boy had to go through something like that if he didn't need to."

In the end, Mom agreed to vaccinate her boy against hepatitis A, influenza, and chicken pox, all that same day. She also agreed to vaccinate him against measles, mumps, and rubella, only if we could give those as separate shots.

Done!

I felt a real sense of accomplishment. Partially because of me, this little boy would now be protected against several serious diseases.

My opinion: Why every child should be vaccinated

Vaccines in general arguably represent the single most important development in medicine, ever. Some people may counter that antibiotics are a more significant advancement, and I'll give them that it would be a good debate.

But think for a moment: What would the world be like today if no vaccine had ever been developed? Just for starters, the world would still be ravaged by smallpox, a disease that few people can truly appreciate how devastating it really was. To put this in perspective, the Wikipedia page refers to smallpox in the past tense, citing its eradication in 1979! Then there's polio, which is so very close to also being referred to in the past tense thanks to a coordinated worldwide campaign to eradicate polio. Warehouses full of people living inside iron lungs are a nightmare of the past; we will never again have a President of the United States confined to a wheelchair because of polio.

Measles (one of the M's in MMR) is a great example of a horrific disease that practically disappeared because of population-wide vaccination but has recently made a resurgence, partly owing to the people who were never vaccinated against it. Measles is an incredibly infectious disease, which means that it's very easy to spread from one person to another. That in turn means that eradicating it will be that much more difficult, especially if there are significant pockets of the population who are susceptible to it. Recently, PBS reported on a mini-outbreak of 13 measles cases after the 2012 Super Bowl; all 13 cases had opted out of the MMR vaccine. In developed countries, one person will die of measles for every 1000 people who get the disease; mortality jumps to 5-10% for measles infections in developing countries (PLoS Med. 2007 January; 4(1): e24). Those are odds I wouldn't want to play around with.

The logic is simple: If you're vaccinated against Disease X, then you will not get Disease X. Given that the consequences of getting many of these preventable diseases include permanent disability, or worse, death, it's hard for me to understand why loving parents would would choose to not vaccinate their child.

A special mentor

The second half of my pediatrics clerkship was much better than the first half. This was partially thanks to working in a practice that focuses on special needs children, an interesting twist to what otherwise would have been three weeks of garden variety ear infections, upper respiratory infections, and stomach aches. But I mainly attribute the quality of my outpatient pediatrics experience to my preceptor. She's a role model for the kind of physician I hope to become, even if I won't be going into pediatrics.

She makes a real difference in her patients' lives; they travel surprising distances just to see her. She is a passionate advocate for her patients' physical and mental health in the context of an often hostile health care system. She is an excellent clinician, able to identify the rarest diseases with simple observations accumulated over her decades-long career. And in her spare time, she has traveled throughout the world participating in medical aid missions. She loves what she does and gains true satisfaction from her work.

I wish I could have spent more time with her.