Frustration and lack of supervision

[Tangerine123]

This thread is basically just to vent. I feel lost and frustrated with my current PGY2 rotation.

For context:

I'm an IMG (Non-EU, non-native german speaker) psych resident in Germany. Currently on my 5th month of a 6th month rotation at an addictions ward. We are 3 residents for aprox. 37 patients. There is no hierarchy among residents. A PGY1 has the same responsabilities and ammount of patients than a PGY5+. My other 2 co-residents are 5th year Neurology residents with experience in ICUs. They have helped me A LOT when it comes to somatic issues. They have no previous experience in Psych.

The main issue: we get little to no supervision.

Rounds with the attending are once per week. Sometimes he rounds without us, our attendance is "optional". Today there were 2 of us. So he said he will let us do everything and he would just write. I thought it was a joke at first, but after a long pause I took the initiative and explored the patients and decided the course of action.

We also have contact with him when we admitt a patient. Patients MUST be evaluated by an attending when being admitted, but not when being discharged. Usually he pops by 30 seconds or so and just agrees to whatever therapy we (residents) decide or recommend and leaves

I think my attending is inept.

*Not knowing the mechanism of action of a common antidepressant when talking to a patient
*Disregarding interactions and somatic comorbidities. Child Pugh C with Valdoxan???
*Buprenorphine and Levomethadone the same day????? I had to step in the next day, after the patient had developed severe withdrawal symtoms, to change the orders and make the treatment transfer slower
*Listing all of the antidepressants to a patient and then just ask them to pick whatever they want, almost randomly without any consideration
*Young patient with a Borderline Personality disorder with a weird mixture of 4 different antipsychotics?????

I've tried and be pro-active and ask things to try and learn. But his answers are always mediocre at best and he dismisses my concerns. So all i'm left with is books and reputable (?) sources on the internet.

This leads me to another source of my frustration. I'm struggling with self learning. International (American) books are somewhat useless and sometimes even detrimental because guidelines and approved medication/dosages are different. I've bought many books, but I feel they contradict eachother and i'm finding psychopharmacology every time more and more confusing. Learning by doing? My experience in other wards is that every attending has their own concept and go-to medication and dosages. I find it extremely hard to find consistencies and many times I can't find any scientific source to back those decisions up.

I won't escalate the situation to the chief of the clinic because they are really close. My attending has been here for decades. These things are known among everybody. How I see it, is that he managed to fall into the cracks of the system. It's a ward that doesn't bring much money to the clinic, there is no research going on and most people dislike the patient population. So nobody asks questions

How am I coping with this? I try and finish everything as fast as possible and head back home to play video games.
I feel like i'm not learning
I feel that i'm incompetent
I know that my patients are recieving mediocre treatment
But I can't get myself to care anymore. I'm showing more and more symtoms of depression. I booked an appointment with my psychiatrist today and i'm glad I only have a month left at the ward

Thanks for reading

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[Sushirolls]

It is tough place to be when your staff is less engaged.
I tactic I used back in the day was to exude extra enthusiasm, and energetically try to set up extra time to go over cases. But have an agenda first. I.e. the example above you gave about just randomly picking SSRI. Feign exuberance and be like your approach to picking an SSRI with the patient, its different, can you share with me your experience to this method?

It might, just might, be possible that if you set the tone as the excited overly interested 'learner' you might tap into the teaching spirt of this lack luster attending. You might not get a lot of teaching moments, but if you focus on one question and frame the question right, you might just get a bite from this fish and reel in some knowledge.

Or you extra put yourself out there. With this patient, I thought this diagnosis, but also this diagnosis, ultimately selected this diagnosis. Do you follow my thinking on this case, does it sound like I'm on the right track? In other words put more of yourself out there and sort of force the teaching comments. It just might work? If not, survival like you're doing is about as good as it'll get.

Good luck.

This also might be a delayed learning rotation. That years down the road, when you process everything that happened on this rotation it might make more sense. System level care delivery. Management of patients. etc

I had one rotation as a medical student, that just irked me for years. Incredibly unprofessional from the primary care attending. But now, years down the road, how that doc interacted, and how the patients interacted, certainly wasn't academic/professional, but the doc was the right doc for the right patients in that unique practice environment. I now understand and get why it came to be - now I just laugh and smile thinking back on. A delayed lesson. I hope that this rotation might offer that up for you years from now, even though its not the lessons you crave now and of relevance now.

 

[FlowRate]

For a concrete suggestion, the Maudsley's Prescribing Guidelines in Psychiatry is a UK-based book so might be somewhat more relevant to you.

Although you're a bit early in training to be given completely free reign, the upside is that it's actually a nice opportunity to formulate and implement your own plan rather than just being an orders monkey for the attending. It would certainly be nice to feel like someone is actively watching to ensure you don't screw up but, if we take your side of this experience at face value, that's just not the lot you've been dealt.

 

[clausewitz2]

Do you have to pay for access to AWMF guidelines over there? It looks like they haven't published formal German-language guidelines for all the areas of psychiatry you might want but you could supplement with NICE.

Alternately, you might look at the Dutch national practice guidelines : GGZ Standaarden

I am guessing their formularies are a bit closer to what you are working with. And if puzzling it out in the original is a bit tricky, many of them have been described in English language publications. They also tend to be very explicit with their reasoning and thorough and practical in the aspects of each problem they consider. They are also very opinionated for the most part and take some strong stances, albeit ones they offer reasoning to justify. For instance, and near and dear to my heart, they generally come out -against- starting medication and therapy at the same time for simple reasons of muddying the waters of attribution of treatment effects, positive or negative.

Hope that helps!

 

[SeniorWrangler]

Bad training with uninvolved attendings is not confined to Germany! If you have any supervision or access to attendings outside your ward, you can ask questions there. This is actually a very good opportunity for your learning, believe it or not this is how residencies in the US used to be (except that we did have a hierarchy of residents so the R3 or R4 was the authority) and you'll learn less in your next rotation when the attending just tells you to do X because he always does X.