July 1, 1979. One of the more frightening days of my life. I was a first-year general psychiatry resident, and it was my first day at New York Hospital-Westchester Division. All of the patients were in a circle with the nurses, the 3 residents who were leaving, and us—the 3 new residents. As the patients, some of whom seemed to be under-medicated in a way we rarely see anymore, went into primary process vocalizations, I felt like I was on a different planet and didn’t understand the language.
I could feel how anxious I was, along with the creeping sensation that I might have made a mistake going down this road. When the morning session ended, one of the patients assigned to me grabbed the leg of the resident who had been his doctor and begged him, “Please don’t leave me with him,” meaning me. And it took all of my self-control not to grab his other leg and say, “Please, I made a mistake, don’t leave.”
Life is made up of many decisions, some of which are based on careful consideration. Others amount to capitalizing on lucky accidents. I think my first and most important piece of advice to psychiatry residents is to expect, and plan for, both sorts of choices. That is certainly my experience. I made a very deliberate choice to give up pediatrics for psychiatry, typical for many psychiatrists, because I could already feel the frustration when the most interesting cases are taken away from you. “You’re going to get bored in pediatrics,” my mentor in medical school, Dr Charles Botstein, told me. “You should pick a field on the frontier.”
And I surely felt like I was on a frontier that day in 1979—a frontier farther out than I had anticipated. I’m sure you are all familiar with the fear and uncertainty of residency; it comes with the territory. But my decision to pursue a fellowship in child and adolescent psychiatry was directly tied to that first day, the realizations I had, and the opportunity to work with kids during the general psychiatry residency.
What did I realize? It's simple: with kids, the prognosis is much better. I chose to work with children because I truly enjoy it, but also because I saw an opportunity to prevent and minimize what I saw in White Plains that first day. Of course, this is not to say that treating and caring for adults with psychiatric illness isn't rewarding. But with young people I saw that I could treat someone with 6 months (or even 2 years) of symptomatic behavior as opposed to someone who has been living with and adjusting to a disorder for 20 years.
So, while my first year in general psychiatry was very traumatic and dramatic, the opportunity eventually to work with kids with psychiatric disorders was incredibly rewarding—and that feeling continues to this day. Since completing my fellowship in 1983, I have never passed a single day when I regret making the decision to become a child and adolescent psychiatrist.
I also have never regretted doing a research fellowship, another fairly random opportunity that made me a better doctor and a better thinker. When I stumbled into research, I realized that one did not have to make a choice—that my experience in the lab would make me a better clinician at the same time, sharper, more cautious, and less likely to make erroneous assumptions and generalizations.
I love my job and am happy with the choices I’ve made. Still, my advice is not that you become a child psychiatrist—although you should, by all means!—but that you remain open to the opportunities that surround you every day as you continue your education and professional training, even while you plan diligently for the future. Some final thoughts:
• Allow what you learn to permeate your life. This doesn’t seem like much of a task to you now, I’m sure, but you will learn so much about the human condition in the coming years. Give this knowledge to your family, friends, and the world.
• Accept and cherish novelty. Learn from your colleagues, and savor the rotations that take you furthest from what you think you want. These frontiers are where inspiration lies.
• Go where the problem is. The landscape of our profession is always changing, these days in exciting ways that will shape your career. But there will always be underserved populations, and people who fall through the cracks. I guarantee that if you identify unmet needs and strive to meet them, your professional life will be, despite difficulties and frustrations, ultimately incredibly rewarding.
