What is the Life of a Transplant Psychiatrist Like?

Session 181

Dr. Robert Weinrieb is a Consultation-Liaison Psychiatry Fellowship Program Director and full-time Transplant Psychiatrist. Today, we talk about his path and his experience in helping students, fellows, and residents so they end up in the careers of their dreams.

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[01:45] Interest in Psychiatry and Transplant Psychiatry

What drew Robert to the field was his curiosity. He also enjoyed his rotation in Psychiatry. Robert was a good listener and someone people would go to for advice and guidance. He was particularly interested in the neurobiological aspects of the way the brain works. And it turned out that he trained in a hospital that no longer exists.

That being said, Robert had a great learning experience as well as lots of exposure to diversity in the West Village.

At that time, it was also at the peak of the HIV/AIDS epidemic. And so, a great percentage of their patients were sick and they died, which was something they had to deal with. It was something they had to learn quickly being in it.

There were only around six of them around the country who worked with transplant teams. Robert did a fellowship in addictions. Upon finishing the second year of training, his program director got a letter from somebody in liver transplant looking for someone in their fellowship who might be interested. Since a lot of their transplant patients had alcohol problems.

It so happened, too, that his best friend’s dad who was also his teacher needed a liver transplant and they weren’t sure about whether to go forward. So Robert watched a bunch of surgeries and went out on organ procurement. He fell in love with the field and realized pretty quickly that psychiatry was a huge part of what they did.

However, there was almost no research at the time. So he had to write a grant if he wanted to keep going at Penn. Seeing there wasn’t one paper on the treatment of alcohol use disorder, it was his first grant.

'Transplant psychiatry is a special interest group within it. And now there are lots of people who are doing the work.'Click To Tweet

Consultation-Liaison Psychiatry used to be called Psychosomatic Medicine. The thinking behind this was to convince other doctors that the mind and the body were connected. But the name just had a negative connotation to it among patients. So they changed the name back to Consultation-Liaison Psychiatry.

[10:07] The Biggest Myths or Misconceptions Around Transplant Psychiatry

'Our role is not to be like the Roman Emperor, we don't go in and say yes, transplant, no don't transplant... what we do is we try to find them a path toward transplant.'Click To Tweet

Robert describes their job as no small task, especially now with the growing demand for psychiatrists. And it’s even harder to find a therapist primarily due to issues associated with insurance.

A couple of years ago, he became a full-time transplant psychiatrist so he could take care of his patients longitudinally. He also brought along one of his fellows to serve as an attending. And they’re now the only program in the country that has two full-time transplant psychiatry attendings.

Being able to see what areas of psychiatric, emotional, or even family problems might interfere with the transplant process, they’re able to shore that up and develop a treatment plan.

[13:28] Biggest Traits to Become a Good Transplant Psychiatrist

Be really good about not being afraid to say I don’t know, and ask questions. You also have to be adventurous. You can’t worry about nine to five because transplant doesn’t work that way. If there’s a case that needs to be seen, and the decision has to be made within a few hours, you have to show up and just do it. You’re part of a team doing the same thing so you’re not alone.

Flexibility is another important trait, Robert added. You have to be passionate and be good with people because you’re going to meet a lot of people who don’t have a lot of patience. They’re busy. A lot of them are surgeons. Be able to communicate effectively and rapidly and not talk psychobabble.

[17:11] Typical Day Pre-COVID

Most days, Robert would have outpatient scheduled, either pre-transplant for heart, lung, liver, and kidney or post-transplant. Then during the day, or in the afternoon, they would sometimes get consulted to see emergency consults. For instance, a liver transplant recipient who became delirious in the ICU. And you’d have to do the differential diagnosis and look at all the meds list and interactions and understand what’s happening there.

They also go to patient selection meetings where you sit with 20 or 30 other people with different specialties and knowledge bases. It’s everything from finance, nutrition, and social work, to the surgeons and the chief transplant surgeons. They listen to how they talk about decision-making for these cases and then put your two cents in at the same time. This takes up a number of hours.

Robert sends a fair bit of time talking to family members. A lot of times, patients are a little too sick. And so, you need collateral information to get a full or accurate history. They also do a lot of writing and teaching, for which their transplant team has a huge reputation for doing that.

[19:06] What Calls Look Like and Life Outside of the Hospital

Robert explains there’s no typical call for them. It’s more of they’re there whenever they’re needed. And good thing there are two of them so they could spot each other, which would have been otherwise difficult if he were alone.

'Call in psychiatry is not anywhere near as arduous as a lot of the other specialties depending on the program that you're in.'Click To Tweet

Robert gives credit and respect to their residents who have been working very hard when they’re on call especially, those working in the crisis response centers of emergency rooms.

Robert says he still gets to have a life outside of the hospital. These days, partly due to the pandemic, they’re seeing cases of acute alcoholic hepatitis. They’re usually people in their 30s and 40s who are getting cirrhosis in their 30s. And so, when they’re being called, they have to plan for it and they could just come to the hospital the next day.

[22:23] What Makes a Competitive Applicant

From a program director standpoint, Robert points out that the residents who do apply already know that they’re interested in consultation liaison. And usually, it’s because they’ve had enough experience by their third or fourth year to understand what that means.

'You don't have a lot of data to guide you for a lot of things so you have to come up with stuff. The most fun part of it is solving the puzzles.'Click To Tweet

Robert says he looks for people who are not afraid to work hard, are flexible, and who can say they don’t know. Because you can’t know it all. And you have to be able to know when you know something and know when you don’t. Get help in those areas.

[24:30] Overcoming Bias Towards DOs

Robert found that the way to do it is to interject yourself into the care of the patient, make rounds with the team, and make yourself known and valuable. But if you’re just the psychiatric equivalent of being a firefighter and just put out the fire and get out, you probably won’t get to know people and they won’t understand enough of what you do.

“When you're able to show what you can do to help people, things will start turning around.”Click To Tweet

[26:12] Message to Future Primary Care Physicians

Robert wishes to tell primary care physicians to keep an eye open for illnesses where you don’t know whether or not you can actually make it better in time for them. If you have somebody who is languishing, depressed, they’re not doing well and they need a heart transplant. And if by the time they get a heart transplant, they’re so sick. This means they haven’t really been able to take care of themselves because they weren’t able to get the right care for their depression early enough.

Especially in alcohol, a lot of these patients need to be sent to programs. They need to be told very directly that they cannot drink because it will kill them because just telling them to cut back doesn’t work. Get them into treatment because if they do those things before they come for a transplant evaluation, it is seen as a very positive thing. And it’ll turn their lives around.

[27:51] What He Wished He Knew Earlier About Transplant Psychiatry

Robert wishes he had known earlier that the breadth of their abilities, and what’s needed of them. Because even if there are so many areas they can help with, you can’t do everything. You have to tailor your skills and also your time to what you can do.

And so, Robert wants to point out how great of a field Transplant Psychiatry is because it’s always moving forward.

[28:52] Most and Least Liked Things

Robert loves working with other specialists – cardiologists, pulmonologists, hepatologists, as well as all the surgeons and nurse coordinators, and social workers. Because everybody’s got a different opinion. Everybody knows things that they can teach one another.

Robert also loves the patients and learning from them. These are folks who were in terrible shape, some of them dying. And they teach you about resilience, strength, and what it means to face these illnesses with grace.

On the flip side, what he likes the least about the field is the paperwork. Especially when you’re working at an academic medical center, you’re always getting tons of things that you have to fill out and stay on top of. But he admits he’s at a point in his career where he doesn’t really have to deal with a lot of difficult things now.

[31:07] Major Future Changes in the Field

When Robert started their fellowship, he began to notice how much other fields needed them. And so, he got the sense that psychiatry was going the way of all the other areas of medicine by developing sub-specialties within the field. So that was how he designed their fellowship.

Most fellowships are inpatient, on the wards and in the whole hospital. Theirs is about 50% outpatient, and in six or seven subspecialties – anesthesia, pain, neurology, women’s mental health, oncology, GI, and transplant.

So he thinks people are going to have a niche within psychiatry that they can really call their own and distinguish themselves from others.

'The knowledge that is required for so many different things in medicine allows you to master something a bit better.'Click To Tweet

[33:22] Final Words of Wisdom

If he had to do it all over again, Robert says it has been everything he has always wanted and didn’t know he wanted until he found himself there.

Sometimes, you just have to get all this experience and then make a gut decision based on all of that experience and knowledge. And if you follow it, you’re probably going to be right and happy.

Finally, what he recommends to students who might be interested in the field is to rotate with him on the wards. Psychiatry residencies now have a good balance of psychopharmacology and counseling, and also self-care, which is something doctors didn’t learn many years ago.

Finally, Robert reveals that a lot of the programs are filling now. People get paid well in this field. You’re not going to be rich. But you’ll be comfortable. And if you love what you do, it’s fine.