Some of the many things that I learned on my Psychiatry rotation at Elmhurst Hospital were about the different factors that impact a patient’s stay in a psychiatric inpatient unit. I learned a lot about medication strategies for various psychiatric disorders. I also became more aware of how social factors influence psychiatric disorders and their management. I found this rotation to be different than the other rotations I completed since in psychiatry, the patient history is often the most important thing to make a diagnosis and open-ended interviewing skills are a crucial. It is also one of the only fields of medicine where patients are often admitted and treated against their will with many legal aspects involved.

The unit that I was on at Elmhurst was an acute adult inpatient unit. Patients who were known to be at risk of harming themselves or others were admitted from CPEP for additional observation and medication adjustment. The treatment strategy in psychiatry was different than what I had previously encountered. I learned that many patients were admitted due to decompensation because of not adhering to their psychiatric medications. Therefore, the goal for many of them was to titrate the oral doses of their antipsychotics so that they can receive a long-acting injection. For patients who had attempted suicide, the unit served as a safe environment with good observation until their medications are stabilized as well. Each patient received a formal interview at the beginning of their stay and daily follow up visits. As my rotation went on, I learned different interview skills and how to ask questions in an open-ended way in the form of a conversation.

Another important thing I learned about psychiatric medications is that majority of them are inherently harmful to the body often because they need to cross the blood brain barrier. This is unlike medications I have encountered in other disciplines, where medications are mostly used to reduce morbidity. It took me some time to process this idea that when considering benefits vs. risk of psychiatric meds we assess and give more importance to things like mood and function of daily living over lab results and sometimes physical health. Additionally, since psychiatric diagnoses are made by history, they can change over time when more information becomes available from the patient or collateral. However, oftentimes the treatment will remain the same regardless of specific diagnosis.

One aspect about psychiatry that was somewhat difficult for me to wrap my head around was the way a patient’s autonomy is taking into consideration with regards to treatment. Unfortunately, many of my patients had poor judgement and insight into their conditions and refused to take their medications. I learned about the different legal aspects of treatment over objection. On Thursdays, I had the opportunity to observe court where a judge, after hearing testimony from the psychiatrists, the hospital’s lawyer, the patient’s lawyer, and the patient themselves would rule on issues like administering medications, release of patient’s being kept against their will, and assisted outpatient treatment.

For example, there was a patient on my unit who had a delusion that his soul was too pure for medication. Since he had a history of violence in the community and was catatonic on the unit, the court granted the hospital treatment over objection. In order to administer his court ordered medications however, a behavioral code needed to be called to restrain him and administer them intramuscularly despite him having been relatively calm on the unit. This was the first time I had ever witnessed a behavioral code and I had conflicting feelings about it. On the one hand, I knew that he needed the medications in order to get better so he could return to the community. On the other hand, it was difficult to witness an adult lose his personal autonomy and be forced to do something against his beliefs even if those beliefs were based on bizarre delusions.

            An opportunity that I appreciated having at this rotation was being able to observe ECT in the PACU. There was a patient on my unit who had treatment resistant schizophrenia and was receiving ECT. I observed how with each session his mood improved and he became a bit more expressive. Dr. Ladapo, one of the chief psychiatrists at Elmhurst explained to me how ECT works and different considerations for electricity dose and therapeutic seizure duration as well as adjusting a patient’s medication accordingly. I also had a chance to talk to the anesthesiologist on the case about managing the airway and choice of sedation and paralytics.

I also had the opportunity to interact with the social workers and psychologists on the unit. I have a new appreciation for how they take social factors into consideration when making arrangements for a patient for discharge. They taught me about housing concerns, the shelter system, as well as what services are available to those who lack insurance and how family dynamics come into play when treating psychiatric patients.

In conclusion, I gained a lot from this rotation and learned many new things. I now appreciate how an inpatient psychiatric unit runs, legal factors affecting treatment course and the different things affecting a patients stay. I also learned about legal processes and different outpatient services available to my patients once they leave. I also have a better understanding of the need to be familiar with different drug interactions and their impact on a patient’s other medical conditions. I will take this experience with me and incorporate knowledge that I have acquired.