Combining Invasive with Intrusive

art-for-invasive-and-intrusiveIt’s 2:00 AM.  I’m on night-float.  I just finished seeing my eighth psychiatric emergency.  One was admitted for disorganized psychosis, one for suicidal depression, and three for detox.  Three were malingering, seeking shelter and a regular meal from the healthcare system; homeless individuals with desperate, desolate lives.  Lives I assumed to be largely self-determined as was my own.

Sixteen years into a busy clinical and academic career as a board certified gynecologic oncologist, I left my comfortable life to enter a residency in psychiatry.  Nearing the age of 50, being married for two years to a wonderful wife, and having a one year-old daughter who is the light of our lives made this choice both more important and more difficult.  

Why did I do it?  To gain a deeper understanding of the anxieties and existential crises I have witnessed in so many cancer patients, and to learn how to better help them.  But was I really prepared for the transitions that followed?  

To re-enter residency, I (and my family) left a comfortable existence in a substantial home in the suburbs to live in a two-bedroom, walk-up apartment and accepted a 90 percent reduction in income.  Rags to riches, but in reverse.  I did this knowingly and willingly with my wife’s permission and support.  Though there was trepidation, our decision was not difficult; it seemed to be the right thing to do.  But the reality that followed was difficult.  

“How does it feel to be a resident again?” residents, nurses, medical students, and attendings ask me, repeatedly.

“I don’t have a problem being junior in status to residents half my age, let alone attendings who are younger and have significantly less clinical experience than me.  They know more than I do about psychiatry.  That’s appropriate.  The issue for me is not knowing…not having the expertise about what I’m doing on a daily basis that I’m accustomed to having.”  

This is my stock answer.  It’s true, but there’s more to it.  

I entered Ob/Gyn residency almost 25 years ago, when the fall of the Berlin Wall was a recent memory.  I was nervous but excited, filled with passion for my chosen career.  Being up all night, on-call every second or third night and working the next day was the norm back then.  Hearing my father’s Ob/Gyn residency training stories helped to shape my expectations.   Eighty hour work rules and night-float rotations didn’t exist.  It was tiring but just seemed normal.  I remember, as an intern on the labor suite, delivering ten babies overnight and in between the last episiotomy repair and the next “catch,” reading a chapter in one of the many phonebook-sized text books (that I read from cover to cover twice) while standing at the nurses’ station so I wouldn’t fall asleep.  I rarely entered the call room.  I just kept pushing, reading, working, striving to know all that I could.  While some residents complained about the workload or their lack of sleep, I plowed through it, frequently staying later to check on patients or inform families.  Sometimes I would stay just to hold a newborn I had delivered into this world.   

Tonight, as I crawl into my call-room cot for a nap sure to be interrupted by the plight of another pathetic soul, all I can think is, “I haven’t been home with my family for three nights and I have two more to endure… What am I doing?  Have I made the right decision?  I’m too old for this.”  I think of myself as somebody who is in relatively good shape but the past twenty-some years have never felt as heavy as this minute.  “It’s the fatigue taking over,” I tell myself, pulling up the covers, closing my eyes, trying to dream of the future.  “Tomorrow will be another day.”

While the physical demands of residency are more grueling to me now, the real challenge for me is relinquishing my independence, accepting I have little control over my day-to-day activities, and swallowing my opinions about the priorities and expectations of the residents and young attendings around me, which are both naïve and appropriate.  Having been a resident, fellow, attending and mentor of residents gives me insights that cannot be expected of them.  I think they should live through the process without some know-it-all like me interjecting.  So I try to observe and appreciate the maturation process that spirals around me and has become a part of me.  Learning to quietly observe is a growth experience for me.


About nine months ago, I was called by a nurse on the inpatient psychiatric unit.  “Ms. Jones is agitated and writhing in pain.”  When I arrived the patient had already been partially sedated and placed in isolation.  She was an obese 20-some-year-old female with a history of bipolar disorder and borderline traits, presenting with significant tenderness and guarding in her right lower quadrant.  Her medical history included an appendectomy and multiple episodes of symptomatic ovarian cysts.  Although she was likely just acting out, there was a reasonable chance that she could have had an intraperitoneal process, possibly a ruptured ovarian cyst or even a torsed ovary requiring surgery.  

When the on-call Ob/Gyn resident said, “We don’t evaluate patients like this on the psychiatric unit.  You should send her to the ED and they will call us if they think it is a gynecologic problem,” I swallowed my pride and took a deep breath, re-explaining my concerns, and suggesting an ultrasound to rule out an adnexal cyst or torsion.  When she disregarded my concerns the second time, I attempted to gain her allegiance by explaining, “Although I am currently a resident in psychiatry, I’ve been a gynecologic oncologist since 1999.  I don’t really think this patient has a surgical problem; however, with her history, I would really appreciate an official evaluation from the Ob/Gyn service to ensure that she doesn’t need urgent surgical attention for torsion.”  I can’t remember exactly what she said but it was something like, “Well you’re a psychiatry resident now.  And you’re asking my opinion as an Ob/Gyn.”  

Something inside of me snapped but I was able to hold it together with a sarcastic, “Well thank you for your help,” response prior to hanging up.  It took a moment to regain my internal composure.  I called her attending, apologized for bothering him instead of his resident, and introduced myself as a gynecologic oncologist currently in psychiatry residency.  I presented the case to him and he immediately sent the resident up to evaluate the patient by exam and ultrasound.  I walked off the unit prior to her arrival to avoid further confrontation, satisfied that the appropriate precautions were taken for our patient but frustrated.  My choice to enter residency in psychiatry put me in a situation where I am surrounded not only by others who, in fact, know more than me about psychiatry, but also by many who perceive my prior experience and expertise as irrelevant.

While I never considered myself a materialistic person, I find myself yearning for the day I return to my comfortable home, drive my convertible, vacation in luxury hotels in interesting and beautiful locations, and not think twice about spending a little extra on dinners at nice restaurants.  I consider the possibility that I may never regain the means to enjoy the materialistic pleasures as easily as in my past.

Still, when I think of the trade-offs that accompany this career transition, the balance still tips toward moving forward.  The decision to combine my previously invasive field of knowledge with this intrusive one invaded and intruded on my life, but it is the right decision for me despite its challenges.  So I push on with cautious, uncertain optimism, reminding myself that change is difficult.

David Silver, MD left an established career and practice as a gynecologic oncologist to train in psychiatry. He is now is third year psychiatry resident at Penn.

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