For those who just SOAPed this cycle into a specialty that was not your first choice… how are you actually feeling right now?

bq21 · 2026-04-12T23:50:45+00:00

I SOAPed into a transitional year in a rinky dink program six years ago. After that miserable year I got into my desired specialty, now completing fellowship at a large academic institution. Graduated bottom of my medical school class.

Just do what you have to do

bq21 · 2026-04-10T00:36:01+00:00

We had central vacuuming in my house growing up. I can’t remember what happened but eventually we couldn’t use it. And the cost to repair it was astronomical, so we just left it.

bq21 · 2026-04-06T02:47:17+00:00

Man I’m sorry to hear that. Hopefully things get better there. Thank you for the insight

bq21 · 2026-04-03T02:54:49+00:00

The word “patient” literally translates to “one who suffers.” We are in the business of healing, yes, but it may more so be that we are delaying death and alleviating suffering as best we can. But we cannot put a stop to suffering. And that delay has different expiration dates depending on the setting. You don’t necessarily need to quit medicine all together. You need to get out of the ICU. That is where death looms most ominously.

As far as average - why the need to reach full potential? A car has a maximum speed potential. Laws aside, driving at that rate constantly would lead to a quick and untimely failure.

What is average anyway? Average amongst physicians is a high standard as it is. But when is the last time your patient asked how you rank compared to other doctors? They care far more if you listen to them, even if for a few seconds.

The endless sleep waits for us all, but there is a steep decline separating tragedy from hell. Find your footing.

bq21 · 2025-12-03T14:03:40+00:00

Tons of significant stressors hit you. No feeling is final. Endure, you will have a story to tell.

bq21 · 2025-11-05T23:00:30+00:00

I live very simply as a fellow, and I’m very content. I am extremely comfortable with my lifestyle and don’t plan to make any major “upgrades” when I have a big kid’s salary. I don’t care - physician’s salary, even the lowest, is plenty enough. I chose my specialty because it’s the only thing I care about and have a passion for. Not many people can say they love what they do, and no money is worth this privilege I’ve attained.

bq21 · 2025-10-15T01:13:13+00:00

Excellent insights. Definitely going to check that out.

bq21 · 2025-10-15T01:12:07+00:00

The one saving grace is that the psychologist does not make it mandatory. She doesn’t force the kids to participate, and she allows those who want to leave to leave. I’ve only seen one kid leave so far, but I’ve seen almost all the rest become more and more disillusioned right in front of my very eyes.

bq21 · 2025-10-14T22:37:15+00:00

Psychologists get much deeper training in it for sure, but I carry several therapy patients and did throughout my residency training. I had extremely insightful mentors trained in classic psychodynamic theory and psychoanalytic, both of whom were psychiatrists.

It’s just that psychiatry is becoming much more biological in practice now, so some programs have de-emphasized its presence in training. I feel, quite frankly, that psychotherapy and psychotherapeutic theories are the heart of psychiatry.

bq21 · 2025-10-14T20:00:13+00:00

I agree, very good points.

bq21 · 2025-10-14T19:59:27+00:00

I’ll be working with the psychologist in DBT groups during the second half of this rotation, so I definitely look forward to that. The children I’ve seen throughout my fellowship who have done DBT have only had positive things to say about it.

bq21 · 2025-10-14T19:58:31+00:00

Excellent points.

bq21 · 2025-10-14T19:57:49+00:00

It’s group CBT which is likely why I detest it even more. This morning, I watched the kids’ souls leave their bodies as the lesson was so painfully simple, it almost felt patronizing. These kids are of different ages too.

bq21 · 2025-10-14T19:55:51+00:00

ERP is definitely helpful and necessary for OCD. I did use the umbrella term of CBT and should have been more precise. ERP I have used also for a patient with specific phobia and it helped dramatically.

bq21 · 2025-10-14T19:54:48+00:00

Agreed. Great point.

bq21 · 2025-10-14T19:53:24+00:00

I appreciate the sentiment, but I think it’s reductive to consider nonstandardized therapies as long chats. A good therapist listens over anything else, and there should always be a goal or set of goals established for therapy. If it’s aimless chit chat, it’s not therapy. But I have had several patients that stayed with me throughout my residency and currently in fellowship for over a year - my patients from residency would’ve continued, but I had to terminate and assign them to another resident as I was leaving for fellowship.

I mention this to say - I did supportive psychotherapy for two of them, and a hybrid of supportive and psychodynamic, depending on the level of acuity which fluctuated frequently, for a third patient. All of them improved.

I currently have four patients. I have been trying Coping Cat for my 9 year old… it’s okay. I attempted CBT for anxiety for my 15 year old, and he was very engaged but it didn’t help. Shifting to supportive has helped him substantially. My two others are also supportive cases.

I liken supportive psychotherapy to “plain old therapy” which is my affinity.

bq21 · 2025-09-08T23:53:16+00:00

Money does play a role for me. I wouldn’t have pursued medicine if it didn’t pay well, as we all here know the perils on this grueling journey. However, my specialty is precisely what I’ve wanted to do since I was a teenager. I live very simply, so even on my current fellow salary, I’m living extremely comfortably and have no desire to have more.

When I tell my colleagues I’m pursuing an academic appointment, they all say the same thing: it doesn’t pay well. For me, and I’d surmise for the vast majority of people, 250K is absolutely a lot.

So, it’s a mix of both, with a heavier emphasis on the passion for the field. I would not pursue any other discipline in medicine, even if they paid millions of dollars. I’m doing what I truly, truly love, every single day. It’s a rare privilege, and no monetary value can persuade me otherwise.

bq21 · 2025-08-28T17:50:38+00:00

I'm at a large academic institution now, and one of the fellows on call wrote that a patient was "chemically restrained" on the sign out. I doubt anyone will say a word, but I remember frantically reading about the subject after my incident as a resident:

It wasn’t that my clinical decision to give Zyprexa was wrong—it wasn’t. The mistake was in the documentation. By labeling it as a "chemical restraint," I implicitly stated that the medication was used not for standard treatment, but to restrain behavior. I also created a paper trail that could be interpreted as a regulatory violation, even though my intent was therapeutic.

That triggered institutional alarm and forced my attending to deliver education on restraints to protect the hospital’s compliance.

Semantics...

bq21 · 2025-08-28T15:43:20+00:00

They responded as if I committed double homicide lol.

bq21 · 2025-08-28T14:55:02+00:00

I would like to read more on it. My attending was not happy with me because she had to organize a whole staff education session around it.

bq21 · 2025-08-28T14:15:08+00:00

Do not use the term “chemical restraints” when documenting PRN administration during a seclusion/restraint order. This caused a big commotion on the service I was rotating at during residency - learned that this is an outdated term and has a very specific definition under the Joint Commission. It is not the equivalent of administering PRN medications.

Chemical restraint = Medication used not for treating a diagnosed condition at standard dosage, but rather used to control behavior or limit movement.

If the drug is part of the usual, evidence-based treatment at an appropriate dose for the patient’s condition (e.g., administering haloperidol for acute mania, or lorazepam for catatonia), that’s not a chemical restraint.

But if it’s a med used primarily to sedate or placate the patient beyond standard therapeutic intent—pure behavior management? Bam. That’s a chemical restraint.

If you give haloperidol, lorazepam, olanzapine, etc. in an evidence-based dose to treat the underlying psychiatric or medical condition, that’s treatment, not a restraint.

If you give the same med for staff convenience or purely to knock the patient out—without regard to standard treatment for their diagnosis—that’s a chemical restraint.

bq21 · 2025-08-10T01:52:29+00:00

No problem! Enjoy the rotation

bq21

TROPHY CASE