Psychiatry Was a No-Brainer for This Doctor

Session 129

Never bored, Dr. Amy Barnhorst recounts the excitement and variety that come with being an academic psychiatrist. She’s been out of training now for 10 years.

She’s now at UC Davis and does some amazing things with gun control and tons of awesome outreach to the community.

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[01:08] Interest in Psychiatry

Amy didn’t know what to do initially but she knew she didn’t like psychiatry. She had never met one so she didn’t understand what they did.

It didn’t really seem like medicine to her until she did her clerkship when she realized what psychiatry actually was. That it was in fact very medical and that it was really fascinating and interesting. She saw there was a huge need for it.

“So many of the other problems that people struggled with were behavioral or psychiatric in nature.” Click To Tweet

Additionally, she had these two interns she worked with that she just really connected with and really liked. They were funny, interesting, well-rounded people with a little bit of a dark sense of humor. She knew they were her people.

Anybody who knew her would have said she was on the track to being an ER doc. She was a rock climber and did a lot of wilderness first aid. She used to teach mountaineering courses in Colorado. She did a lot of outdoor stuff and this is kind of the lifestyle for ER docs.

That being said, she thought that the ER lifestyle and practice was a really good fit for me. She also thought a lot about going into family practice because she was interested in public health and preventive care.

Before she actually went to medical school when she didn’t know about anything, she wanted to be an epidemiologist and an infectious disease doctor. And it was right around the time that the movie Contagion came out. She was also reading a book about infectious diseases back in the late 90s while she was doing her prereqs.

She relates the Ebola epidemics with the gun violence problem, saying that gun violence problem in their area is not just about the lethality of the weapons. It’s about the social and the political and the economic drivers.

[04:36] Biggest Misconceptions or Myths Around Psychiatry

One of the biggest misconceptions people have about Psychiatry is that psychiatrists are just mostly bearded old men who wear tweed coats with elbow patches. They sit in a chair while their patients talk. And every 10 or 15 minutes they say, “tell me more, tell me more about that.”

But Psychiatry offers an incredible variety of practice settings. You can work in the emergency department and see people in acute crises and dealing with a lot of methamphetamine and PCP intoxication.

You can see people in a psychotherapy clinic where actually you do need some training to know when to say, “Tell me more about that.”

You can also work in an inpatient psychiatric hospital treating people with serious chronic mental illness. You can work in a jail, you can work in an outpatient medical medication management clinic.

“Psychiatry has all of the possibilities in one specialty.” Click To Tweet

Amy didn’t really get any sort of pushback from family because none of her family and friends were in medicine. And so nobody knew enough to say one way or the other.

Psychiatry is generally a pretty happy specialty and they really enjoy our work. They find their work very meaningful because other specialties rely on them too for consultations and referrals. In preventive care, psychiatric interventions and behavioral interventions are so important. Once you can get over the slight ego hit, it’s really worth it.

[08:20] Traits that Lead to Becoming a Good Psychiatrist

Psychiatrists are very meticulous. They’re very detail-oriented. They like to make personal connections, move really slowly, and get to know their patients and their families. People do really well in outpatient clinics where they have a lot more time with folks and things aren’t quite as acute.

Whatever your personality traits are that leads you to a certain style of practice, there’s a match for you in psychiatry.

One of the main things is you have to be a little bit introspective enough to know what it is that you’re bringing to the table versus what it is that actually is from your patients.

So much about psychiatry is from the interaction with the other person. And if you don’t know that, the tension in the room may actually be from you or that the reason that they’re acting removed and quiet is because you’ve pushed them away or rebuked them in some manner.

If you’re not willing to acknowledge what it is you bring to the table, it’s hard to be a good psychiatrist in any of those settings.

In psychiatry, they really encourage residents while they’re in training to do their own personal therapy. This way they have a better understanding of what their own personality traits are. And they get to understand their assets and flaws that they bring to every relationship whether it’s a professional one or a personal one.

“Having a good perspective on yourself is crucial. And without it, people can get into a lot of trouble.” Click To Tweet

There needs to be some coping skills as well as a personal perspective to be able to do this kind of work.

Moreover, there’s like a little bump on the other end of people who were here because either they’re trying to rectify their own bad experiences and their mental health care. Or they want to know what it is that’s made them suffer from psychological problems all their life. And that’s why they focused on this. So there’s this other subset of psychiatrists that you aren’t quite as well-adjusted. 

[12:38] Typical Day

There is not a typical week for her. They’re an integral part of care for a lot of the teams plus the emergency department. It really relies on them for taking care of patients in the ED because they’ll have up to 20 to 30 patients on a psychiatric hold in any given day.

Amy will be consulting on those patients and seeing people in the ICU, on the surgical and medical floors in the hospital. Amy is also involved in her firearm violence prevention curriculum project. Apart from this, she is the vice chair in my department, covering for her chair while she’s gone. She’s doing some meetings with hospital leadership about a new unit being developed.

During her free time, she’s finishing up a one-pager for one of their Congresswoman. She requested about the methamphetamine crisis in the Western States and how it contributes to homelessness and increasing crime rates. Also, talkabout increased health care and psychiatric bed usage so that she can learn about how to formulate legislation from that. So her week is basically all over the place.

[15:07] Taking Calls

Amy covers call for the jail, for the county inpatient hospital and crisis unit, and UC Davis hospital. If it’s on a weekend, she goes in and sees patients. Depending on the site, it might take her around 1-8 hours on a Saturday or Sunday.

So one in 10 nights, she’d have to go in. But mostly, it’s home call and fielding pages about dealing with a headache or chest pain and whether the person needs to go to the ER. 

[16:06] Life Outside of the Hospital

Amy is very adamant about making time for her two kids. She had them when she was a medical student and learned very early on that she needed to cut things out if she was going to survive.

If you don’t weed out stuff for a month, you slack off year, it’s just going to get overrun with things that you didn’t want in there. 

“It’s a very active, deliberate process, looking at what you've taken on and saying, do I want to be doing this? Does it bring me joy?” Click To Tweet

Before she does something, she’d have these questions: Do I want to be working with these just people? Is this something that is in line with my personal or career goals? Do I feel like this is contributing meaning to the world? Is there somebody else who could do this instead of me?

[18:18] The Training Path

Amy went to UC Davis medical school and did her training there. She left for three months and then came back and joined the faculty. This being said, she didn’t have a lot of perspective in other places.

After medical school, she elected to do two months in the emergency room and did an extra neurology. She took an EKG reading course because a lot of their medications have cardiac implications.

Intern year is six months in medicine, six months in psychiatry and neurology. Depending on how your program breaks it up, you may be spending between 2-5 months doing inpatient medicine.

In general, the view was that psychiatry residents hated their internal medicine inpatient months. And the internal medicine inpatient people felt about the same about them cause they were not there to manage people’s electrolytes.

But Amy actually loved her inpatient medicine months. She felt so productive and empowered and there was so much learning while taking care of patients.

If you want to be a child psychiatrist, for instance, that’s a two-year fellowship on top of the four years of regular residency training. You can start those two years, the first one can be a one-year long elective of your fourth year.

It’s like fast-tracking things and getting the whole package done in five years.

There are also other fellowship opportunities including PSM (psychosomatic medicine) or constantly liaison fellowships.

You get to learn a lot about just being a consultant in the hospital for other teams, how to manage difficult patients in the hospital, how to make decisions about things like capacity to make medical choices a much more medically focused subspecialty.

Other fellowships would be Child and Forensic.

“Forensic fellowship is the interface between psychiatry and the law.”  Click To Tweet

Forensic fellowship involves everything from doing evaluations to determining if people are incompetent to stand trial due to a mental illness or if they’re not guilty by reason of insanity.

You’re going to be working in jails and prisons. You’re also going to be doing some civil stuff, a lot of the firearms work that involves mental health law. So it helps to have more of a forensic background.

[22:29] Most and Least Liked Things

Amy loves the variety. She loves having a week where she’s doing policy work on methamphetamine and curriculum and educational work on firearms and clinical work in a medical hospital and a crisis unit.

“There's just so much variety and there's so much need.”  Click To Tweet

Then she’d be down at the jail next weekend and just getting to be all over the place. Amy feels that as a psychiatrist, you can move almost anywhere in the country and get a job. There’s no area where they say, “We just have too many mental health providers right now. That doesn’t happen.”

On the flip side, what Amy likes the least is what she considers as a personal problem that applies to her whole profession.

She sometimes wished she had more practice with basic medical skills and primary care. She’s wondering that if there’s an emergency on the plane and she’s the only doctor there, is she even going to remember what to do. Or is she just going to be asking the person about their mother and she just won’t raise her hand in those situations.

[24:34] Overcoming the Mental Health Stigma

There are going to be some students who continue the stigma because they haven’t been exposed to much mental health. How do we as a society start to help us realize that depression isn’t just because the person’s not trying hard enough or whatever other stigmas are out there with mental health?

There is a lot of stigma out there and it applies differently to these two groups. One of which is people with serious mental illness. And the other is people with psychological issues or lack of psychological wellness.

People with serious mental illnesses like schizophrenia and severe bipolar disorder represent a really small percentage of the population. Interestingly, a lot of medical students have never seen somebody like that. They’ve never met a person or spent time with a person who’s in the throws of psychosis.

“A surprising number of students come to rotate in some of the really acute environments and they don't believe that mental illness exists.”  Click To Tweet

That being said, it’s easy for people who have never been around it to just discount that it’s really a thing and really a problem.

It’s a huge thing and a lot of people suffer from it and don’t have support and don’t have the resources. 

There are also people who aren’t aware of what an actual serious mental illness looks like. They confuse it with mental unwellness. But that’s not to diminish the struggles of people who have things like social phobia, anxiety, and  mild depression.

Amy also thinks that it’s great that a lot of famous people have recently come out and talked about their struggles. It helps normalize things.

She is seeing this new trend where younger people are able to talk about this kind of stuff and they’re able to seek help because they have role models in the media saying they have this issue.

It’s great that people are more open about their struggles with their emotions, with their difficult times, and with sadness or anxiety.

However, it draws some tension away from what actual real mental illness is because it’s a much more serious thing.

People who are struggling with schizoaffective disorder are not the ones out there walking on the red carpet and saying every once in a while that they have this problem. They’re the people who have really fallen off the curve of society and lost their families and lost their homes. They lost their jobs, their insurance,etc. So it’s a really different group of people.

[29:42] Major Changes in the Future

Amy thinks we are going to be moving more towards procedural psychiatry such as electroconvulsive therapy and to more transcranial magnetic stimulation.

There haven’t been that many breakthrough psychiatric drugs on the market recently like in the sixties and seventies when antipsychotics really hit the market. It was a huge change in the way things were done, not just in terms of treating individual patients but the nationwide system in general.

Now, people with chronic psychotic disorders could actually get better. The depressants though were heralded as being equally amazing when they came out. They’ve not quite panned out to be so dramatically awesome. That said, people are going to start looking towards other modalities.

[30:59] Fixing Gun Violence Issue

Amy says she got involved in this as the voice saying that this is not a mental health or a psychiatric issue, particularly when people would really turn the mass shooting discussion towards it being a mental health problem.

She knows how hard it is to really make a diagnosis of mental illness in people that actually just seem really angry and entitled and unempathic. It’s much harder to treat those traits in someone and it’s pretty futile to keep them in a hospital. 

And that’s if the police actually are able to find them and bring them in, which oftentimes they don’t.

Amy first got involved writing some opinion pieces for the Sacramento Bee and also for The New York Times. She talked about what it actually looks like on the ground to say the mental health system is responsible for this, like where that logic falls apart.

Amy thought this wasn’t a viable solution, but now she has seen the nuts and bolts of why it’s not.

Her main role is to explain that with the existing civil commitment procedures and mental health law, the mental health system was not going to be a viable option for stopping mass shootings in this country.

“How much of the violence here is not due to mass shootings and how much suicides are not clearly preventable by just hospitalizing everybody with depression.” Click To Tweet

[33:45] Final Words of Wisdom

Amy admits she was sorry she didn’t become an ER doctor but the reasons she didn’t become an ER doctor still stands. The main one being that she can’t really stay up past 10:00 pm.

Therefore, she still would have chosen Psychiatry if she had to do it all over again because mainly of the variety. Whatever setting fits her lifestyle as well as the needs of her family, her kids, what kind of schedule she can have. She likes how she’s able to adjust things.

Finally, she wishes to tell students that psychiatry can be a very evidence-based medical specialty and it is one that is so necessary.

You will always have job security. Your patients will always need you and so will all of your colleagues. You will never be bored because we still don’t know the half of how the brain works yet.

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