Jacqueline A. Basha, MD

Clinical Instructor, Department of Psychiatry
Columbia University

If I had a millions hands, each with five fingers, I probably still wouldn’t have enough to count the number of times I moaned to myself or to my mother that my psychiatric residency was way too long.  “Whose brilliant idea was it to make it a four full years?” I’d gripe. “Three would be plenty, two even, don’t you think? After all, this isn’t brain surgery we’re learning, it’s Psychiatry.”

So I graduated feeling at least a year, maybe two, overcooked and more than ready to be out in the big world, free of supervisors and classes, free of someone looking over my shoulder and asking me why I hadn’t asked the patient to do serial sevens, or why I’d picked this drug over that one and if I’d considered other options. By this time I was more than qualified…wasn’t I? All I really needed was a job and I was off to heal the world. 

My job search began about two months before graduation with me actually answering the calls and emails from medical recruiters that in previous years I normally would have ignored or deleted at the first possibly opportunity. The first one I read that seemed genuine was to become my very own recruiter, whom I was sure would find me a job.

ME: I want to work in Manhattan

HER: So will you consider taking a job in Stamford CT? How about Rhode Island? Rhode Island really needs psychiatrists. Have you considered Texas?

After politely declining a number of interviews scheduled to take place on a weekday morning at least two hours out of the city, I decided to break up with my recruiter and start handling things on my own. I read The New York Times, The Psychiatric Times, Psychiatric News – I even read Craig’s List (which, by the way, has little in the way of psychiatry jobs). It was now a month before graduation, a month before my loans would begin to accrue interest (which I assume meant that the principle would get really big really fast) and I had nothing but a stack of crossed out classifieds. Panic was setting in, which was closely followed by insomnia, anorexia, emotional liability, and symptoms of PTSD. Either I was having some type of break, or I wasn’t dealing with the reality of the job world very well. But lucky for me, desperation led me to act most out of character and randomly email the director of the hospital where I most wanted to work. He just happened to need a psychiatrist and was willing to take one that was just completing training. After all, residency was four full years…
I accepted my job about twenty-five days before graduation, which brought with it an immense amount of relief. Look how mature I was! I’d found my very own job all by myself, without the help of my mother or a recruiter or even Craig’s list! In retrospect, perhaps I should have asked about things like salary, benefits, starting times – did I get a salary and health insurance?  Yes.  That was all I needed to know. Doctors shouldn’t need to worry about things like that…should they? Yikes. Lucky for me, my place of employment is fair and just – but had they not been, I never would have known until my bi-weekly check was in one hand and my rent bill in the other.

So with the hard part out of the way, I figured it would be clear sailing from that moment on.  After all, didn’t I now know everything there was to know about psychiatry? Hadn’t I spent a year, maybe two, too many, learning what was now my second nature? I was the mechanic; psychiatric illness was the misfiring engine. I was the plumber; my patient was the cracked pipe that I would simply mend and make as good as new. I was about to be an attending! How many times had I wished I was the attending, certain that with me at the helm, there was no way the ship would sink.

Clear and confident in my identity as an Attending Psychiatrist, I arrive on day one of my new job to find myself in the midst of many far more senior Attending Psychiatrists, not to mention medical students that seemed far brighter than I had even been at their age, and a number of senior residents that seemed incredibly confident and far more comfortable in their psychiatric identity that I was suddenly feeling.

And then came the questions.

“Why would you call that patient hearing voices schizophrenic and that other patient hearing voices PTSD? Don’t they both meet the DSM criteria for schizophrenia? Maybe she’s not flattened, maybe she’s just shy? Maybe it’s cultural, is that possible oh supreme attending of just one day? How can you be sure? How can you be absolutely certain that you’re not making a mistake…”

Suddenly I hadn’t a single answer. Not a word, not an opinion, not an ounce of confidence in the “excess” training I’d received. All my previous truckloads of confidence were being undermined by the enormous amounts of fear being generated by my amygdala

“Doctor, you have call from a family. They want to speak to the Attending Psychiatrist. You have a call, it’s from the director of hospital X that wants to know if you will speak with them about patient Y. Doctor, do you think the chest pain is cardiac or just anxiety, can you please assess them for capacity to refuse treatment…” And so on.
 
What was happening? Why wasn’t I as overly confident and prepared as I had anticipated? Could it be that I actually wasn’t ready? Why was the transition that I had mistakenly anticipated as simply making a lateral move turning out to consist of the sharpest learning curve of my life?

I’ve been at the job a month now, and most of my ability to command the English language has returned. This past week I was even able to voice an opinion contrary to someone more senior than me. Of course my opinion was wrong, but nonetheless, voicing it was a step in the right direction. I’ve gone back to my old interview technique books, I’m rereading the DSM with a heightened level of attention to its subtleties and differences that I would previously skim like a recipe I’d made a thousand times; and I’m having another go at the psychiatric bible sometimes referred to as Kaplan and Sadock. I’m reading how-to articles on teaching and I’m writing my notes with a renewed level of meticulousness that I haven’t possessed since second year college calculus. Basically, I’ve returned to the fundamentals…and I’ve gotten myself a private supervisor whom I actually pay. What I’ve learned is that if medicine really is a lifelong learning process, then perhaps four years of psychiatric residency wasn’t too long after all.