Utopia: The Transition From Inpatient to Outpatient Psychiatry

March 21, 2013
Marley Doyle, MD

Outpatient psychiatry is a critical experience in becoming an independent psychiatrist.

Our residency program is traditional in that there is an abrupt transition from inpatient psychiatry to outpatient work. During the early years of training, this transition possesses a magical quality. I pictured the outpatient setting to be Utopia, a carefree land filled with promises of motivated, high-functioning patients, easier hours, and a better quality of life.

The reality has been much different, however. Being someone’s therapist and, sometimes, primary support system, was terrifying. I felt that the patient’s success in therapy (and in life) depended on me. At first, it was difficult to accept that patient outcomes are not entirely my responsibility. I felt like an intern again, fumbling my way through and hoping for the best. It was as if I was standing in front of a locked door, one to which only more senior residents and faculty had access. They seemed so much more knowledgeable that it made me wonder what was behind this door. Perhaps there was a helpful psychotherapist who whispers insightful interpretations in your ear, whenever you don’t know what to say.

The realization of my ineptitude became salient during supervision. In one instance, after going into great detail about my patient’s early years, I brought up an awkward moment in our last session. The patient spoke about her conflicting emotions towards her mother who had schizophrenia. With 5 minutes left in our session, the patient asked abruptly, “What are you waiting for?” At first, I thought maybe I looked bored or she was waiting for me to wrap up the session. Needless to say, I was taken aback and stammered, “What do you mean?” She responded, “What are you waiting for? Why don’t you have kids yet?” This was the last question I expected. I had no idea how to respond, so I sputtered, “Uh, well . . . busy, I guess.” The patient looked at me quizzically, “Busy?” “Uh, yeah, just busy.” Wishing desperately to change the subject, I offered the patient an appointment, and she was out the door.

Only then did I realize that the patient could not have known if I had children. I had no idea what she was trying to communicate by asking this question. And, even worse, we had just had a lecture about how to respond to patients asking personal questions. When I shared this experience with my supervisor, she could not even answer right away because she was choking back tears of laughter (in a good-humored way, of course). We spent the next 30 minutes talking about ways I could have responded, all of which would have been better than my answer.

Is outpatient psychiatry the Utopia that was promised? Hardly. But it is a critical experience in becoming an independent psychiatrist. In the past few months, I have gained confidence in my abilities while recognizing that I still have much to learn. I am more comfortable with living in the gray and not feeling like the patient’s entire life is in my hands. And, yes-the work hours aren’t bad either.