Psychiatry Residency Program – Day in the Life

Currently, I am on my inpatient psychiatry rotation on Pratt 2 at Tufts Medical Center. There are a total of 18 patients on the unit, divided into two, attending-lead teams. There are two residents—one intern and one senior resident—assigned to each team, so at any given time, I'll have 4-5 patients of my own.

We see a huge variety of mental illnesses and large range of severity. Being located in the heart of Boston, we also see patients from all different backgrounds and cultures. Tufts Medical Center is a "safety net" hospital, which means we treat patients regardless of their ability to pay for treatment.  

I get to the unit around 8:00 am so I have time to pre-round on my patients. My pre-rounding consists of looking at my patients' charts in our electronic medical record system and talking to the nurses who took care of my patients overnight. With the information I gather, I come up with an assessment and plan for every patient. Just before 9:00 am, I check in with my medical student, who is carrying for two of my patients. I do a little last-minute teaching to help them develop their assessment and plan a little further.

We begin rounds at 9:00 am with my attending, our social worker, my co-resident and my medical student. Our nurses come in to tell us about overnight events, and then we bring in patients to the rounding room to interview one by one. I interview my own patients, but my attending usually jumps in at the end. When our patient leaves, the entire group convenes to discuss our thoughts and plans for the patients. My attending uses these opportunities to teach and I find it very helpful when she explains her thought process about using specific medications, and formulating the patients in general. My medical student is carrying for my remaining two patients and shares their plans, too. I am discharging one patient today, so I prepared their discharge summary and orders yesterday so that it's ready for today. Everything is all set for my patient to leave by 11:00 am this morning.

We finish rounds around 10:30 am. I take some time to talk to my medical student about the day ahead. Now it's time to get to work: I have patients to see. I try and spend 10-45 minutes with each patient; everyone's needs are different. After that, I sit down and write my notes. Sometimes I have other responsibilities on the unit. For example, somedays I met with a patient and their family to discuss their post-discharge care. With the remaining time I have, I teach my medical student about a topic of their interest.

At 5:00 pm the day residents sign out to the overnight on-call resident (PGY2/PGY3). As a PGY1, I take long day call.  This means that 1-2 nights a week, I will help out the overnight resident until 8:00 pm, usually by admitting new patients to the inpatient unit and helping out with any unexpected issues that come up on Pratt 2. However, I can also be asked to help out in the emergency department (ED) or consultation liaison service CL service.

The Pratt 2 week is over before I know it, and it's time for the weekend. Two weekend days out of the month, I'm on call at the hospital. I arrive to the hospital at 8:00 am to take care of Pratt 2, the ED, and consult psychiatry patients. Like my weeknight call, I have a senior resident and medical student to help me. I'm finished by 8:00 pm. For all other weekend days, I am completely free—my computer is shut down, my phone is on silent and my pager is off!

I commute on the train ~20-30 minutes and show up around 8:00 am to run the list with my co-resident and our medical students. We get sign-out from the overnight residents on any new ED/CL cases as well as any events overnight. The students help with pre-rounding so it gives us an opportunity to teach and to be more thorough with our patients. We run the list with our attendings and the team (which includes our NP and SW) to see who we need to follow up with from the days prior. Throughout the day, we will get new consults from the floors and ED. If we have questions, one of our Consult Liaison (CL) attendings, Dr. Montalvo or Dr. Radhakrishnan is on site and always available to help guide us. This gives us the opportunity to learn how to develop our own formulations and plans. We are consulted for a variety of different questions, which keeps things interesting. For example, we get asked to help with determining capacity, managing delirium and/or agitation, and optimizing outpatient psychiatric medications for medically ill patients. Throughout the day, we will staff our patients and follow up with any additional things. It can be busy but we learn a lot on this service. There is also always time for teaching students and getting some learning from attendings on service.

As a second year, I also have my own outpatients that I schedule throughout the week, and my co-resident covers the service during those times. I usually have about one to two outpatients in the afternoon. I also can have supervision with my outpatient supervisors. It is exciting to get to learn about the outpatient psychiatry as a PGY2.

On a typical day, we sign out to the overnight resident at 5:00 PM and I am home by 6:00PM! Unless I'm the resident on call, then I hear about the cases from all of our teams (Addictions and the Inpatient Unit). This is only 2-3 times a month and then the next day I get a post call day. Most nights I usually see one to three ED cases and manage any issues on the unit. It can be frightening overnight but I know my attending is only a call away to help if I need it. This program provides a lot of autonomy, and I have noticed so much growth in my confidence and knowledge in just one year!

9:30 am – 1:00 pm: Outpatient psychiatry and medication management appointments.  I sneak in a brunch/lunch sometime in here as well. I'm a night owl, so I tend to see patients later in the morning and finish up later in the day. Since we do our own scheduling at Tufts MC so I can tailor my schedule to my own preferences.

1:00 pm – 3:00 pm: General psych intake clinic with Dr. Paul Plasky. For this weekly clinic, I see a new patient seeking to establish care with outpatient psychiatry. It's usually Dr. Plasky, another resident, one or two medical students, and me in the room with the patient. I love watching how Dr. Plasky approaches a new patient and quickly establishes a rapport with them while obtaining a comprehensive history. Afterwards, we discuss a formulation and plan moving forward. We invite the patient back to ask some more questions and discuss the plan together. If we agree that the patient would benefit from outpatient treatment, I will work with them going forward. I currently follow around 30 outpatients,   but we have various specialty intake clinics with different outpatient attending physicians throughout the year, which will give me a larger and more diverse outpatient case load over time.

3:00 pm – 5:00 pm: Outpatient psychiatry and medication management appointments. I usually have one patient after intake clinic. The rest of the time is spent finishing up notes or taking care of other administrative tasks. On other days, I have supervision during this time. Seeing each of my 2 supervisors once per week is really the highlight of my week, since they help me see different perspectives on my patients, understand the art of outpatient psychiatry, and give me guidance on how to approach my outpatients when I'm not sure what to do.

After work, I typically go for a run, cook and relax for the night. On weekends, if I'm not traveling, I try to spend one day at home just relaxing with my husband and the cats and one day downtown with friends. About once every 14 days, I am on call and spend my post-call day running errands and then relaxing at home. 

As Administrative Chief resident, it's hard to describe a typical day since my role is so varied in its responsibilities, but I'll do my best!

This year I carry a smaller outpatient load than I did in my PGY-3 year to allow for my additional administrative responsibilities, so I usually have at least a couple of appointments every day. I really enjoy having the flexibility in my schedule to see my weekly psychotherapy patients and to allow for close follow up with some of the more acute patients I have on my panel.

In addition to meeting with both of my outpatient supervisors every week, I also have a weekly meeting with Dr. Morehead to discuss the state of the residency. As Administrative Chief, I act as a sort of liaison between the residents and administration, so there's always a lot to talk about! Recruitment season – in which I play a central role – is on the horizon, so that has dominated the discussion for the past few weeks. We've also been discussing new electives, including one with a ketamine clinic that I will be piloting later this year.

I do a good bit of teaching, so lately I have been focusing my efforts on developing basic psychopharm lectures for the PGY-1 and PGY-2s which is a lot of work. It's almost like you could write a whole textbook on this stuff.

Outside of work I've been keeping myself busy with many different things. I've been interviewing for jobs post-residency, moonlighting (which you can start doing as a PGY-3), playing some new video games and traveling with my wife.