Acad Psychiatry 29:386-387, October 2005 2005
doi: 10.1176/appi.ap.29.4.386
© 2005 Academic Psychiatry
A Day in the Life
Psychiatrist-in-the-Making:
Jillian Evans, M.D.
My day begins each morning around 8:00 a.m. where I tie up loose administrative ends. Today I call the husband of a woman who was seen yesterday in consultation. The woman is a 54-year-old mother of three adolescents who has recently been diagnosed with breast cancer. Undergoing chemotherapy, she became agitated and confused. The consultation documented an acute organic brain syndrome. After the phone call to obtain extended information, I see a new consultation involving a 27-year-old man who was in a motorcycle accident and is now paraplegic. The individual continues to believe that he will walk again, despite complete transsection of his spinal column. His prior history reveals him to have antisocial traits, as well as history of substance abuse, and the need for ongoing follow-up and transition to a rehabilitation center are among the tasks at hand. After lunch, consultation-liaison rounds are held where my two cases are presented to the faculty attending. I then go on to meet with the trauma team, which makes rounds regularly on complicated patients, and I also have an opportunity to present the young man seen in consultation this morning. The day ends with a few more phone calls to attending physicians or residents.
A unique aspect of our program is that we write orders for medications or lab studies rather than suggest such interventions. This fosters increased compliance and denotes the active consultative model we utilize. Peer support from my other fellows, as well as interaction with faculty, students, and residents offsets the inherent stress of working with the critically ill in high-stress technological settings. Liaison assignments complement the consultative experience. I have the privilege of working with a breast cancer survivor group. These incredible women share their stories, coping tactics and compassion for one another as they navigate their difficult journey. Other liaison activities include joining geriatric and trauma teams wherein physicians, nurses, pharmacists and social workers regularly attend to particular issues around their subspecialty with specific patients. The liaison experience allows me to get to know the staff of the various units in an ongoing manner and allows understanding of the unique issues in each setting.
The second element of the fellowship is clinical supervision. We have formal rounds three times a week with a C-L trained faculty member. All cases are review. Once a week a patient is interviewed in depth in our C-L case conference and pertinent literature is presented. Dr. Crone, our program director, and Dr. Wise are always available for immediate advice and, if necessary, direct observation of emergent problems. Supervision also includes a weekly conference with a senior psychoanalyst to discuss the psychodynamic aspects as well as group process of interesting consultations. Individual case supervision is assigned for ongoing outpatient treatment which is much like our experience as a third- and fourth-year resident.
The didactic aspects of my fellowship include two journal clubs. The first is a weekly clinical topic in C-L led by Dr. Wise. The second is a weekly general journal club on a broad range of psychiatric topics wherein faculty, residents and students attend. A substance abuse seminar is important, since many of our patients have comorbid addictive disorders. A seminar is a behavioral neurology course led by a faculty member jointly trained in psychiatry and neurology. This helps us with the regular patients we see with a variety of CNS disorders and also helps for our psychiatric board exams. A course on research design and reading the medical literature have helped me better understand whether the evidence presented in a study is sound.
My research experience involves working in a Phase III drug trial of an antidepressant that may offer some pain relief, as well as mood elevation. I have been able to attend the investigators meeting and take part in protocol development, as well as follow patients with the ongoing protocol. My day usually ends at 5:00 p.m., although I am on call for patients after those hours. Although the week is a busy one, there is little to no evening or weekend work in the hospital.
This brief review cannot do justice to the total experience of a consultation fellowship. I learned far more than I thought I would in a fellowship year. I was very pleased with my basic residency at Johns Hopkins, but a fellowship year allows for a more focused in-depth experience. At Fairfax, fellows do not evaluate the self-harm patients, which allows more time for the traditional medical surgical consult. Second, I was initially overwhelmed by the idea I needed to know internal medicine. Such information is readily available from either textbooks or the online library resources available throughout the hospital. One of the most enjoyable aspects of the fellowship is teaching the medical students and junior residents on our service. The ability to try to organize my thoughts and review pertinent literature allows me to better understand the patients I see and offer important points to the more junior physicians. One of the nice aspects of the fellowship is the comfortable office that is given to each fellow, with excellent computer and online library services.
I am amazed at how much I have learned. I completed a great basic residency, but a fellowship offers new data, new skills and a more sophisticated approach to psychological issues in the medically ill.
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