Bipolar II in Residency

[DestinyRoseAndrews]

Has anyone had bipolar II in residency? What specialties would be most conducive to getting regular sleep as a resident?

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[j4pac]

PM&R is probably one of the lighter programs. Many have a night float internship and home call the rest of the way. It has its own forms of stress and burnout can be high if you’re not a good personality fit. There is arguably more psych in PM&R than any non-Psych residency. The majority of our patients are either in pain or disabled

 

[clausewitz2]

Has anyone had bipolar II in residency? What specialties would be most conducive to getting regular sleep as a resident?

1) Yes. People have completed medical residencies with all manner of serious mental illnesses. Also, other people have washed out of residency and medicine completely due to serious mental illnesses. It is definitely a form of hard mode.

2) Psychiatry is going to generally be a good one for getting sleep as a resident, although often not in the first year. A lot of programs use a night float system which at least involves fewer abrupt transitions but is still going to be a circadian reversal, unless you are presently a vampire.

Here's a lengthy interview with a fairly accomplished psychiatrist dealing with a bipolar d/o:

Synesthesia of Distress And Other Stories: A Q&A with Owen Scott Muir

Owen Scott Muir, MD, is a child and adult psychiatrist with personal experience of mental illness.

www.psychiatrymargins.com

 

[comp1]

Psych probably has the best of the core specialties you might see in 3rd year. I don't know much about PM&R, but it looks like some might require a transitional or preliminary year? I think the OP wants to avoid an intern year like that as they can be heavy duty in terms of workload. Regardless of specialty, you want to make sure that you pick a chill residency location that doesn't utilize residents as workhorses. Work hour restrictions have dramatically reduced how much hospitals can use residents, but it's still common to see those rules pushed at many places. Avoid in house night float at all costs. Particularly for psych there's no need and it doesn't train you for anything you'll actually be doing as an attending. Overnight assessments should be done by social workers or NPs. Residents should be available to give verbal orders by phone with attending back-up for questions.

 

[gutonc]

Psych and path are pretty much the only specialties I can think of that don't have a typical intern year requirement. That said, psych still has 6 mos of IM during intern year and it's inpatient focused in most programs, and with many/most programs now on night float, It's relatively easy to avoid 24+h shifts anymore. I'm well aware that even night float may be too much of a stressor in this case, but it's worth considering.

Once you get through intern year, Derm, Rad Onc, Psych and PMR are all pretty much bankers hours.

 

[mistafab]

Just putting out there please be cautious applying. Some specialties will simply not be possible to train in without risk of decomp. I’m in psych and promise there are great programs out there still using 24s routinely that can destabilize you - even after intern year. If you can, be strategic about where you apply.

Even my buddy in pathology was pulling 24s doing blood bank. It is not common to get through all of residency in any specialty without 24s or call at all - so work with your physician and have a plan, and be smart about where you apply.

 

[shaggybill]

Complete an intern year somewhere and then apply to occupational medicine programs.

 

[annoyedpsychiatrist]

When I was in residency, we had a year where we had a month basically of 24 hour calls, and 2 months of nightfloat. However, there was a resident with a seizure disorder and he was excused from this, and made up the time elsewhere. Some programs will work with you on it, some wont. Im a psychiatrist and I expect that psych programs would be more apt to work with you

 

[DestinyRoseAndrews]

When I was in residency, we had a year where we had a month basically of 24 hour calls, and 2 months of nightfloat. However, there was a resident with a seizure disorder and he was excused from this, and made up the time elsewhere. Some programs will work with you on it, some wont. Im a psychiatrist and I expect that psych programs would be more apt to work with you

Would you say it's possible to find residencies in multiple specialties willing to accommodate someone with the need for regular sleep, or is psych mainly the only understanding one?

 

[rokshana]

Would you say it's possible to find residencies in multiple specialties willing to accommodate someone with the need for regular sleep, or is psych mainly the only understanding one?

maybe family medicine where they are an opposed program and do little to no inpt service.
or do a pgy 1 in something and then do occupational or preventative medicine

 

[NotAProgDirector]

Would you say it's possible to find residencies in multiple specialties willing to accommodate someone with the need for regular sleep, or is psych mainly the only understanding one?

I think you'll find it's a challenge. And it's less about "understanding" than practicality.

Let's look at IM for example. Many, if not all, IM programs will have some sort of night float rotation -- where you're cross covering multiple patients at night, and perhaps admitting some new patients. Many programs split this up into 2 week blocks, and 4-6 weeks of 5-6 nights per week is common. So, about 30 actual night shifts.

So let's say you tell your program you can't do nights. Somebody has to cover those shifts, so some of your colleagues will get extra runs of nights instead of you. Perhaps you're thinking that you'd be willing to do more shifts on weekends to help balance the schedule. But in IM, continuity is important -- just having you there on a weekend is less than ideal, unless you actually know the patients. You need to have days off, so your program is limited in having you work 2 weekend days. And, there may simply not be enough free weekends to actually make it all work.

Plus, many programs will see night coverage as part of their defined curriculum. If so, they do not need to accommodate it for ADA reasons -- it becomes an essential function of the job.

Your best plan will be to speak to programs about this before you match there, so that it doesn't become a fight once you match. It will limit your options, for certain. Some IM programs might be able to make this work. There might even be some without night shifts at all. But you're going to need to do lots of research to find them.

As already mentioned, some fields have minimal night work by design, and would be much easier.

I would not 100% count on psych being easy to avoid night shifts. Will definitely depend on the program.

 

[dozitgetchahi]

Maybe one possible approach is to find a specialty where you can do a “cush” TY (some of these cush TYs can be very very easy), and then actual specialty training isn’t so bad as far as hours go. A good example of this would be derm (obviously the massive competitiveness of derm could be an issue in terms of actually getting into it). Prev med and Occ med would also be good possibilities.

 

[DestinyRoseAndrews]

Maybe one possible approach is to find a specialty where you can do a “cush” TY, and then actual specialty training isn’t so bad as far as hours go. A good example of this would be derm (obviously the massive competitiveness of derm could be an issue in terms of actually getting into it). Prev med and Occ med would also be good possibilities.

How can you get a cush TY?

 

[dozitgetchahi]

How can you get a cush TY?

If you search SDN or look at, say, the derm or anesthesia pages you can probably find posts talking about which TYs are cushy.

 

[NotAProgDirector]

Of course you should assume these will be competitive.

 

[DestinyRoseAndrews]

I wonder if finding residencies without 24 hr. call and chunked night floats would work. It seems like having a consistent schedule would be most important, but I really don't know. It would be nice to hear from those with experience or training in this.

 

[clausewitz2]

I wonder if finding residencies without 24 hr. call and chunked night floats would work. It seems like having a consistent schedule would be most important, but I really don't know. It would be nice to hear from those with experience or training in this.

IPSRT would suggest that consistency in schedule is probably a higher priority and more important than a specific time frame in which you are awake. During those night float blocks you would also want to make sure you ate at consistent times (at least at home) relative to the timing of your shift, exercised at certain times, etc. You would also want to maintain the vampire schedule on days off if they fell within your night float block instead of trying to flip things.

 

[mcatqueen]

I think this will be more program dependent than specialty dependent. There are some PD's who may be understanding and are likely to help you. For example, I know of someone who's PD allowed them to split their 24hr weekend call shifts into two 12 hr shifts that they split with another resident.

The key will be to avoid malignant programs, as some PD's will make things difficult just because they can.

 

[Meerkatology]

When I was in residency, we had a year where we had a month basically of 24 hour calls, and 2 months of nightfloat. However, there was a resident with a seizure disorder and he was excused from this, and made up the time elsewhere. Some programs will work with you on it, some wont. Im a psychiatrist and I expect that psych programs would be more apt to work with you

out of curiosity what kind of stuff would a psychiatrist be called for at night? and would u actually need to physically go in?

ive been a night shift hospitalist for a while and i've never had to call psych in the middle of the night for anything.
the ER does call the PET team for suicidal pts and such to be transfered to inpt psych facility, but im not sure if these really need to happen at night, they should be able to hold in the ER until day time?

 

[Apollyon]

out of curiosity what kind of stuff would a psychiatrist be called for at night? and would u actually need to physically go in?

ive been a night shift hospitalist for a while and i've never had to call psych in the middle of the night for anything.
the ER does call the PET team for suicidal pts and such to be transfered to inpt psych facility, but im not sure if these really need to happen at night, they should be able to hold in the ER until day time?

Psychiatrist I knew said just about that: "Put 'em on ice, and we'll see them in the morning".

 

[clausewitz2]

out of curiosity what kind of stuff would a psychiatrist be called for at night? and would u actually need to physically go in?

ive been a night shift hospitalist for a while and i've never had to call psych in the middle of the night for anything.
the ER does call the PET team for suicidal pts and such to be transfered to inpt psych facility, but im not sure if these really need to happen at night, they should be able to hold in the ER until day time?

In places with freestanding or dedicated psych EDs, someone is manning the place at night. In some places the law regarding involuntary commitments requires the patient to be examined by an MD and the petition upheld at one of a small list of approved sites within a certain time frame. If a psych hospital wants to be one of them, well, MD needs to be available.

In some states at psych hospitals someone being put into seclusion or restraints has to be physically examined by an MD within a certain time frame (often like an hour).

Very rarely some of my colleagues who do C&L work get called in for very urgent capacity decisions (someone conscious enough to actively refuse lifesaving surgery.

For some freestanding psych hospitals, someone has to deal with putting in orders at night. This might be handled via someone on call but if there is a co-located residency program, well, guess who takes in-house call? Some psych hospitals can be quite large and the frequency of calls makes an actual night float a practical solution (like multiple calls per hour).

 

[comp1]

In general, psychiatrists should not have to go in at night and I would be VERY leery of any residency program that had some sort of in house night float. It both is not necessary and also does not train you to function as psychiatrist attendings actually do. In terms of what psychiatrists are called for, it is generally admission orders (usually a standard set), some sort of prn that was missed by the day shift or emergency medication orders for agitation. Psychiatrists are in extremely short supply. Most things that require immediate assessment overnight, such as for involuntary commitment, can and should be done by social workers or other similar professionals. Of course the law varies on this by state, slightly. Even for the strictest of states that somehow expect 24/7 availability of a psychiatrist to do assessments, this should be done via telehealth and not someone sleeping at the hospital or driving in overnight.

 

[Stagg737]

In general, psychiatrists should not have to go in at night and I would be VERY leery of any residency program that had some sort of in house night float. It both is not necessary and also does not train you to function as psychiatrist attendings actually do. In terms of what psychiatrists are called for, it is generally admission orders (usually a standard set), some sort of prn that was missed by the day shift or emergency medication orders for agitation. Psychiatrists are in extremely short supply. Most things that require immediate assessment overnight, such as for involuntary commitment, can and should be done by social workers or other similar professionals. Of course the law varies on this by state, slightly. Even for the strictest of states that somehow expect 24/7 availability of a psychiatrist to do assessments, this should be done via telehealth and not someone sleeping at the hospital or driving in overnight.

As a whole I'd agree with most of this. There are some states where laws require psychiatrists or psychologists to be physically present for restraint orders within a certain time frame (meaning going in overnight), but many do not. I will push back on the bolded a bit as my residency program implemented in-house night float for PGY-1s and 2s during my PGY-4 year after it was highly requested by the junior residents. Previously there was a swing shift that was physically present from 4-10pm then home call until the next morning that was covered in week-long rotations by residents during inpatient months. Broke up the continuity of the rotation unless you were week 1 or 4 and most didn't like it.

It was replaced by a "swing/night float rotation" covered by 2 residents. One would physically be at the hospital from 3-9pm, then another would come in for night float from 9pm until the next morning. Each did that for 2 weeks then they'd switch. Night float would cover the ER and do H&Ps so inpatient residents didn't have to do them before morning rounds. Sounded annoying to me, but the junior classes voted unanimously to switch to that. This was also a program with no required call other than the ACGME required 3 weekend days after PGY-2 (could pick up extra call for pay).

I agree that night float in psych is unnecessary and frankly dumb, but some residents actually like those rotations. Weird, but to each their own...

 

[j4pac]

As a whole I'd agree with most of this. There are some states where laws require psychiatrists or psychologists to be physically present for restraint orders within a certain time frame (meaning going in overnight), but many do not. I will push back on the bolded a bit as my residency program implemented in-house night float for PGY-1s and 2s during my PGY-4 year after it was highly requested by the junior residents. Previously there was a swing shift that was physically present from 4-10pm then home call until the next morning that was covered in week-long rotations by residents during inpatient months. Broke up the continuity of the rotation unless you were week 1 or 4 and most didn't like it.

It was replaced by a "swing/night float rotation" covered by 2 residents. One would physically be at the hospital from 3-9pm, then another would come in for night float from 9pm until the next morning. Each did that for 2 weeks then they'd switch. Night float would cover the ER and do H&Ps so inpatient residents didn't have to do them before morning rounds. Sounded annoying to me, but the junior classes voted unanimously to switch to that. This was also a program with no required call other than the ACGME required 3 weekend days after PGY-2 (could pick up extra call for pay).

I agree that night float in psych is unnecessary and frankly dumb, but some residents actually like those rotations. Weird, but to each their own...

The q3d 12 and 30 hour shifts I had in internship were dangerous. I also had random day and night shifts in the ER that were pretty disorienting. Compared to those setups, a 12 hour night float was really humane. I typically would sleep 1-2 hours during the shift, and would get to sleep more in a blacked out room when I got home. It wasn’t perfect but I think it was fine and I never felt impaired or disoriented like the other two setups.

 

[Stagg737]

The q3d 12 and 30 hour shifts I had in internship were dangerous. I also had random day and night shifts in the ER that were pretty disorienting. Compared to those setups, a 12 hour night float was really humane. I typically would sleep 1-2 hours during the shift, and would get to sleep more in a blacked out room when I got home. It wasn’t perfect but I think it was fine and I never felt impaired or disoriented like the other two setups.

There are far worse shifts than night float in residency, but it's just not common (or medically necessary) in psych. The residents liked it where I went because they'd get 2 weeks of night float then 2 weeks of a 6 hour shift covering the ER and on-unit issues (mostly just PRNs, occasional restraints or AMA discharge) which could be pretty cush. Same thing for the night float. Unless the ER was busy (which apparently only happened a couple times per week), they could just sleep through most of the night. I never had to do it, but it was a pretty laid back rotation where I was.

 

[j4pac]

There are far worse shifts than night float in residency, but it's just not common (or medically necessary) in psych. The residents liked it where I went because they'd get 2 weeks of night float then 2 weeks of a 6 hour shift covering the ER and on-unit issues (mostly just PRNs, occasional restraints or AMA discharge) which could be pretty cush. Same thing for the night float. Unless the ER was busy (which apparently only happened a couple times per week), they could just sleep through most of the night. I never had to do it, but it was a pretty laid back rotation where I was.

So…do people just not cover nights in psych residency…or if they do…how?

 

[Stagg737]

So…do people just not cover nights in psych residency…or if they do…how?

Overnight call is almost exclusively from home. There isn't really anything that would happen that would actually require a psychiatrist to be on-site immediately and hospitals that have in-house staff overnight is more for administrative efficiency than necessity. For "emergencies" it really falls into one of 3 categories. "Psychiatric" meaning active SI or unsafe to be alone which can be managed by a constant observer and psychiatrist seeing the patient in the morning. Medical emergency in a psych patient, in which case a psychiatrist may help pin down a diagnosis (NMS vs serotonin syndrome, vs anticholinergic toxicity vs whatever) but the actual treatment is medical management and care would be done by other docs (ER, IM, etc). The last is an aggressive/non-cooperative patient who poses a danger to themselves or others, in which case the psychiatrist typically talks to a nurse or other staff to have a patient placed in restraints and make medication recs for agitation. Again, doesn't require a psychiatrist to physically be there and usually we are stepping out of the way as police or a behavioral response team steps in to control physical aggression. The last is the situation that some states have laws requiring psychiatrists to come in to see the patients.

Comp1's position that in psych residency night float (or any kind of overnight in-house staffing) is typically unnecessary and does not significantly add to the educational experience is basically correct. My contention was that while I'd certainly be asking about night float if I were an applicant, it is not necessarily a de facto red flag. Psych is a very different experience from a lot of other areas of medicine, and a lot of things that are educationally valuable in some fields just aren't beneficial or even necessary in psych.

To bring this back to OP's point. Psychiatry can certainly be a field where someone with MH problems could have a very reasonable schedule that could accommodate sleep requirements. However, there are other aspects of our field that are stressful in completely different ways for many people that medicine/surgery residents will only touch on or may not experience at all.

 

[mistafab]

So…do people just not cover nights in psych residency…or if they do…how?

just to be clear, many in the thread are conflating “psych” with psychiatry in general. Psych as a residency still has the majority of programs requiring night work, either 24s or night float. Psych attendinghood is very different from psych in residency (like many specialties).

You need to be very careful selecting programs and specialty if you have a condition that can be worsened by chrono-disruption.

 

[fellow12321]

Lithium, antipsychotics such as ziprasidone, quetiapine etc.

Fairly basic stuff.

 

[DestinyRoseAndrews]

Lithium, antipsychotics such as ziprasidone, quetiapine etc.

Fairly basic stuff.

What is this in response to?

 

[Goro]

What is this in response to?

There may have been a post prior to this that got deleted.

This SDN is probably a known troll using a sock puppet account.

 

[DestinyRoseAndrews]

I've been researching specialties and found that preventative medicine has no call, nights, or weekends at least in one place. It also has good ratings for burnout and happiness. You still have to do a transitional year, so I might just be home-free if I can find something with no 24-hour call. The only challenge would be getting a job after the residency since it's not as well known and defined, but it's probably eventually possible.

 

[comp1]

Preventative medicine is a...choice. If you have an actual interest in the field, sure, go for it. You're right that it's relatively quite esoteric, but there's jobs for all physicians out there. However if you're really just looking for something chill, there are lots of other options after that transitional year which you correctly identify as potentially a big issue. There are several categorical years that on average have less workload/call than the average transitional year. Remember, a lot of programs are perfectly happy to WORK YOU during that transitional year because you're not even sticking around.

 

[Apollyon]

There are several categorical years that on average have less workload/call than the average transitional year. Remember, a lot of programs are perfectly happy to WORK YOU during that transitional year because you're not even sticking around.

Categorical first years? I'd really like to see that. Transitional gets the best and brightest, because they're cush. They get something like 8 or 9 months of electives, which means they are NOT getting worked hard. Or, the people going on to rads or anesthesia are doing their electives in them, so, they don't feel like they're being worked.

But, a blanket statement that transitional years are anything but easy is crazy talk. If there are any that are not soft and chewy, that gets around.

 

[xffan624]

I've been researching specialties and found that preventative medicine has no call, nights, or weekends at least in one place. It also has good ratings for burnout and happiness. You still have to do a transitional year, so I might just be home-free if I can find something with no 24-hour call. The only challenge would be getting a job after the residency since it's not as well known and defined, but it's probably eventually possible.

Pro-tip if you apply. It's preventive medicine. Calling it preventative medicine is a quick way to annoy folks in the field. As stated it's a niche residency and the pay will never likely be that high unless you do some concierge type practice and pull out your inner entrepreneur, but most jobs are not that. You only need one year of residency in any capacity. You can search for the forum for my previous posts on the field and residency. The residency is a breeze, mostly. Most require completion of MPH so there is some academic workload involved, but it's manageable and you're not working at the hospital 80 hrs/week on top of that. There's some clinic and some rotations mixed in around the the academic duties. Much of the schedule is likely variable by program.

Final disclaimer: If you don't have any interest in public health at all, I would look for another residency.

 

[DestinyRoseAndrews]

Pro-tip if you apply. It's preventive medicine. Calling it preventative medicine is a quick way to annoy folks in the field. As stated it's a niche residency and the pay will never likely be that high unless you do some concierge type practice and pull out your inner entrepreneur, but most jobs are not that. You only need one year of residency in any capacity. You can search for the forum for my previous posts on the field and residency. The residency is a breeze, mostly. Most require completion of MPH so there is some academic workload involved, but it's manageable and you're not working at the hospital 80 hrs/week on top of that. There's some clinic and some rotations mixed in around the the academic duties. Much of the schedule is likely variable by program.

Final disclaimer: If you don't have any interest in public health at all, I would look for another residency.

Thanks, sorry about that.