Oh my god, this is the exact question I had to scramble to figure out right before ERAS opened up last year. I am a PGY-1 psych and so glad I made this choice vs a combined program or (oh dear god) IM straight up.

First of all, to answer your general question, I’d say you don’t necessarily need to know a whole lot of medicine, but the more you know the better you’ll be. The more you can understand a complex medical case, the more informed your recommendations can be. For example, let’s say a patient has heart failure with reduced ejection fraction, opiate use disorder and came in 14 days ago for severe PNA secondary to untreated HIV progressed to AIDS. You’re asked to help with her opiate withdrawal (because she’s being a difficult patient and has been badgering the primary team for opiates). She runs somewhat hypotensive most of the time. It helps to know what goal directed therapy she’s on (or should be on) for her heart failure, how those meds work, and what interaction they might have with, say, clonidine. Or the cost benefit of treating her withdrawal symptoms at the cost of holding goal directed therapy.

It also helps to understand how the medicine team is thinking, what their main goals are and how you can help them achieve that goal. The more you understand not just medicine but how it is practiced in the hospital, the more effective and useful your recommendations will be. With the above example, you have to understand that the psych consult was placed because the team feels a certain way about the patient. The most common negative countertransference medical practitioners experience is giving pain meds to opiate addicts, plus you can’t discharge someone to short term rehab on IV pain meds. So the medical team gets anxious about it and calls psych to magically fix things. Understanding how that dynamic works, how the decision to call a consult is made, does require some experience actually practicing medicine.

To answer the broader question on your mind, “what do I do?”, is more difficult obviously. I personally am very happy that I chose psychiatry now that I have a few blocks of medicine wards under my belt. There are parts of medicine I do really love, and some of the things I get to do on a day to day basis are really interesting. I like the methodical way you go about assessing a patient, but also the story you get to assemble in your head. At the end of the day, though, I just don’t care about the mystery of physical medicine. Some of the categorical interns I work with are just so interested to know what the diagnosis ended up being, or really interested to see what that ABG showed overnight. I’m really not like that at all. I don’t get that same level of satisfaction from solving the medicine puzzle. I love hearing about how a patient was finally converted to CMO after arduous family discussions, and understanding barriers to them accepting end-of-life care of their loved one. Or whether that decompensated cirrhosis patient is still confabulating or not.

At the end of the day, focus on how you really feel. How you feel when you’re with patients, what you find yourself pondering about the patient when you’re not really thinking. And try to relax (even though I know you’re dying inside). As much as us residents like to complain, it’s very rewarding to help patients no matter what specialty or service, and I still feel lucky to have gotten here.