From the chiefs:
The University of Michigan Psychiatry Residency program is a solid training program that prepares residents for independent practice in a variety of treatment settings: inpatient, outpatient, emergency, veterans’ care, pediatric, substance use, and forensics, to name a few! Residents have an incredible amount of faculty support over four years as we hone our medication management skills, apply a wide spectrum of therapy modalities, learn how to manage crises, and gain understanding of the implications of mental health and mental illness within our society. We are so glad we chose U of M for residency during this critical period of learning at the beginning of our careers. At our program, we believe you will find many people and resources to help you achieve your goals, whether you are considering a career in academics or private practice or have specific interests in patient care, education, or research. We hope prospective candidates will consider joining our U of M family!
Aaron Iuppa, MD, MPH
Stephen Leung, MD
Zane Meibeyer, DO
A Day in the Life of a Psychiatry Resident
Hi everyone! My name is Jess Meves and I’m one of the twelve interns that recently started here at U of M. I’m excited to share with you a bit about what it is like to be a first year resident here. Our intern year is split into twelve one-month rotations. Six months total of the first year is spent on psychiatry rotations (inpatient psychiatry for 4 months, consult liaison for 1 month, substance use disorders for 1 month) and six months are spent “off-service” on non-psychiatry rotations (internal medicine, family medicine, ER, neurology, and possibly pediatrics). We spend the most time at the inpatient unit at the Ann Arbor VA for a total of 3 months of the year. Here is what a typical day looks like on that service:
We arrive on the unit and receive sign-out from the overnight second-year resident who lets us know if anything has happened with our patients overnight. We also hear about any patients that were admitted to the unit overnight. We then spend the first part of the morning looking through the EMR reviewing notes, labs, vitals, as-needed medications administered, and any other pertinent information for our patients. Then we go onto the unit to do our daily interviews with patients, asking about their mood, any changes since the previous day, how they are tolerating medications, sleep, and any other relevant information that will help us determine the appropriate treatment plan.
We then attend a daily Treatment Team Meeting with the nurses, social workers, attendings, residents, medical students, and pharmacists that are involved in the care of the patients on the unit. This is an opportunity to discuss each patient in a collaborative manner. Patients may be invited into the meeting to discuss the goals of their hospitalization, their strengths, and any obstacles they feel they need to overcome to meet their goals.
After Team Meeting we wrap up seeing any patients we were not able to see earlier in the morning. The attendings will often stop by the resident workroom at this time to discuss the patients we have seen and their treatment plans. We then decide when to see new patients that have come in overnight, who we see with the attending. After all our patients have been seen and their treatment plans have been agreed upon, we put in any necessary orders, call patients’ family members or friends for collateral information, and see our patients again as needed to provide updates.
We always make sure to take a break to tend to our own needs—and if you forget, the attendings will remind you! The great part about being on the VA inpatient psychiatry service is that you always have 1 or 2 other psychiatry interns on service with you, and we often try to eat lunch together.
We then spend the afternoon finishing up whatever we have yet to get to from the morning, writing progress notes, and admitting any new patients that come to the unit. If you admit a new patient, you will discuss his or her care with the attending, put in admission and medication orders, and write an H&P. We often have medical students on the service, so the afternoon is a great time to do teaching as well.
At this time we can sign out our patients to the second year resident that covers the unit for the evening and then head home assuming our work for the day is done. Once or twice a week you will stay for “short call” meaning you stay on the unit until around 8pm to take any late admissions that may come in.
On this rotation you will have one or two weekend days off. I love taking this time to explore Ann Arbor, discover new parks in the area, or wade in the Huron River with my husband, 3-year-old son, and 11-month old daughter.
On your interview day I hope you get a sense of how supportive and enjoyable the atmosphere is here. All of my interactions with attendings, staff members, and residents here have been positive, making an already exciting experience that much better.
Hey Everyone! I'm Bailey and I am one of the 12 freshly minted PGY-2's. I have really enjoyed my PGY-2 year thus far. This year we rotate on inpatient child, consult liaison, adult inpatient (at both UofM and the VA), and PES (Psychiatric Emergency Services). You also will have roughly 5 Saturday 24 hour calls in PES - during these call shifts you cover both the inpatient child and adult units for emergencies, take new consults, and cover the psychiatry emergency room. I recently did one of my five 24 hour shifts in PES and I feel they are a great opportunity to learn how to triage psychiatric emergencies and consults that come in. Here is a summary of my call shift:
Take sign out from the PGY-3 who just completed their Friday overnight call. We discuss the patients still in PES, as well as, anything important I need to know about new consults or issues on the inpatient units.
830AM - 930AM:
A patient in the secure core becomes agitated and we administer a one time dose of olanzapine. After about a half hour this patient is still agitated and requires seclusion. I complete these orders and see the patient within one hour of the seclusion order and write a restraint note. I tell another patient in the secure core that he is being involuntarily admitted and complete follow up documentation for this patient. I get roughly 4 new consults in the hospital. Most of them are non-urgent, meaning they are for anxiety or depressive symptoms without safety concerns. At times, for anxiety I may give some preliminary recommendations, such as a trial of hydroxyzine over the weekend. The weekend inpatient and CL Social worker pages me to let me know she is here if I need her.
I get paged about another new consult, which is urgent, a young child post-surgery who is delirious. Since my attending is not currently in-house and is adult psychiatry trained, I decide to page the child and adolescent consult liaison attending for some help with recommendations. The Child CL attending calls me back promptly and we discuss the case at length. This is one of the few times during second year we get exposure to child CL. I plan to try to see this patient today given the delirium is interfering with medical care. One of the PES nurses comes and asks I enter orders for patient in PES who are due for their morning medications.
I get paged by the primary team about a current CL patient. They wanted to update me that the patient is medically ready to be transferred to psychiatry. I page this information to the weekend inpatient social worker. The Inpatient social worker also pages me with updates on other psychiatry consult patients, who are waiting for psychiatry beds, and updates me one patient, who CL has been following, is no longer medically stable for transfer. She usually leaves around noon and lets me know she is heading out.
My Noon to 10pm attending has arrived. I update him on the happenings in PES and any of the new consults I feel are important to discuss. He asks what he can help with and plans on doing follow up notes on the other two patients in secure core. There is a PA who comes in around this time too. They cover all of PES while I take the 10 minute walk to the children's hospital to visit with my child consult I got earlier. When I get to the patient's room the team is talking with the Mother and I spend some time gathering history from mom and evaluating the child. I head back to PES and begin doing my documentation.
I eat some lunch I brought from home and type away on my consult note. PES is starting to pick up but my attending and the PA are holding down the fort so I can stay on top of this note. Right after I finish eating, I get a page about a patient on the adult inpatient Psychiatry unit with Chest pain. I see in their chart medicine has been involved in their care and they were recently diagnosed with new A-Fib. I order a EKG and let my attending know I am going to see the patient. I meet with the patient and complete a physical exam and look at the EKG, both of which are reassuring. However, I don't want to miss anything since the patient is young and this pain feels different that their normal panic attacks. I decided to get troponins and page the medicine team to make sure there is nothing else they would like me to do.
Medicine responds and would like more tests ordered on the chest pain patient. They are concerned about the patient and may want them transferred to medicine. Ultimately, the patient needs to be transferred to medicine. I complete the discharge readmit process and write the patient's discharge summary based on the chart documentation.
I return a couple pages for new consults which are non-urgent. At the beginning of the weekend the CL services send emails on patients that may need to be seen and I reply all on these emails and provide a list of the new consults I got, what the primary team needs from us, and if I saw them. I pend this email as I am sure I will have more updates before my 24 is over.
Take a breather. The PES patient board does not look slammed and my attending and PA have been staying on top of everything. I go for a walk to the cafeteria to grab some stuff and call my partner to say hello.
One of the triage nurses asks me to see a patient who came into PES that might need to go to the Adult ED. I quickly see patient and find out there was an overdose earlier today. We send the patient to the adult ED and the triage nursing completes a petition so the patient cannot leave prior to psychiatric evaluation. I write their name on the white board as to keep track of them. I get paged from the child unit about a patient needing some tylenol and place the order.
I am paged about a possible transfer to PES from the Child ED. This patient has a history of ASD and came in for agitated behaviors and had a negative medical work up. My secure core, where all the high risk and agitated patients stay, is full. I call the pediatrics resident back and explain the patient cannot come here because we do not have a room in the secure core, but would be happy to see the patient there. I write the patient's name on a white board and figure out which SW will be taking the case with me. We both chart review and then walk over to the children's hospital to see the patient.
I staff the pediatric patient with my attending and provide our recommendations for some medication changes and discharge with outpatient follow up with their psychiatrist to the primary team. I complete documentation for this case. My attending and the PA sign out to me and head out for the night.
I got another page for a new consult that is not urgent and add that person's information to my running email with the staff on weekend call and the adult CL team. The patient in secure core becomes agitated again and needs PRN medications and seclusion. I see them an hour later sleeping comfortably and complete restraint documentation.
There is a little down time here so I chat with the social workers I am working with and catch up on some things I needed to get done.
Three people trickle in to PES - one adult and two kids with their parents. I see all three of them and then page my attending to staff them all at once. It seems all three will discharge home. However, as the social worker is working with one of the minor's and the parent, the parent changes their mind and would like their child admitted, which is reasonable. As such, I order all of the admission labs and complete a brief physical exam.
I continue to catch up on documentation. The patient in the secure core becomes agitated again and is placed back in seclusion. I place the orders and go see him to complete the restraint note. I have a cup of coffee to keep my momentum up as another person walks into PES. The Adult ED pages me that one they discharged might come over to PES.
See the one that arrived and the one from the Adult ED who did end up coming to PES after discharge. Staff these both and complete documentation.
I finish my documentation. Sign out to the incoming PGY-2 who came in at 8AM. I tell them about what is going on with all the PES patients and what needs to be done for them, give the PGY-2 the heads up on the transfer to medicine from inpatient psychiatry, and go over all the new consults that came in and who to prioritize seeing if they are able. Send my emails for the child and adult consult sign out and head home.
After my shift I spent about four hours snoozing on the couch with my dog before doing some things around the house with my partner. I spent much of the day recouping and went to bed early.
My name is Stephen Leung, and I’m currently a PGY-3 in the general psychiatry residency program at the University of Michigan. PGY-3 is entirely outpatient and takes place mostly at the beautiful Rachel Upjohn Building, with the exception of some community clinics. We each have our own individual offices in which we see patients on a regular 8 AM to 5 PM schedule Monday through Friday. The academic year is divided into two 6-month blocks. Between the two 6-month blocks, we rotate through various clinics (depression, anxiety, perinatal, bipolar, geriatric, substance use) and psychotherapy mentorships (CBT for depression and anxiety, DBT, IPT, couples therapy, and motivational interviewing). The day-to-day schedule varies depending on the day of the week. Here’s an example of my typical Tuesday schedule.
8:00 AM to 8:15 AM
In our UMATS clinic (U-M Addiction Treatment Services), I start the day by meeting with my attending to discuss a plan for the day. We run through our list of patients and discuss treatment goals. We discuss with nursing staff if we need their assistance in drawing labs or administering medications such as naltrexone injections.
8:15 AM to 11:30 AM
I typically spend 60 minutes seeing a new patient, with an additional 30 minutes to staff the case and coordinate treatment. I usually see two additional return visits in UMATS for the rest of the morning and can typically find time between patients to catch up on documentation.
11:30 AM to 12:00 PM
I meet with my attending to debrief each case from the morning. We spend time discussing anything from articles of interest to interviewing techniques.
12:00 PM to 1:00 PM
Lunch! This is free time to either have a quiet lunch in my office or have lunch outside with my co-residents. At a minimum, the program provides us with a free lunch with educational material two days out of the week.
1:00 PM to 4:00 PM
The afternoon is dedicated to bipolar clinic. Patients are often referred to our bipolar clinic either for diagnostic clarity or for a higher level of care for known bipolar disorder. We see one new patient every other week in bipolar clinic, and we have two hours for the initial intake. This allows us to review pertinent records, conduct a comprehensive interview, and discuss treatment within a multidisciplinary team. The clinic is staffed by some of the leading researchers within the field. By utilizing their knowledge and resources, we are often able to provide treatment that patients may not otherwise receive in the community, such as IV ketamine or ECT. On the days that I don’t have a new intake, I see patients in our bipolar medication group where I work with an attending to see multiple return visits at the same time.
4:00 PM to 5:00 PM
The day wraps up with a bipolar team meeting. If I saw a new patient in the afternoon, then I will discuss the case with the team and elicit their feedback. We have care managers and social workers present in the meeting, and they are extremely helpful in coordinating follow-up and providing referrals. The meeting usually concludes with a teaching exercise conducted by a faculty member.
The above summary is just a snapshot of the PGY-3 experience. In addition to all the various clinics, we also have weekly grand rounds, weekly didactics on Fridays afternoons, and two hours of weekly supervision, one each with an individual faculty supervisor and individual psychodynamic supervisor. On your interview day, I hope you get a chance to see the breadth of outpatient experiences as you tour the Rachel Upjohn Building!
My name is Duy (pronounced zwee) Tran, and I’m a PGY-4 at the general psychiatry residency program at the University of Michigan. This last year of residency is very flexible with 8 months of electives, allowing you to choose rotations based on your professional interests, whether it is to solidify specific knowledge or to explore subspecialties in psychiatry. I decided to do an ECT elective to learn more about this procedure, which I believe is an essential part of psychiatry. This elective takes 3 days out of the week for my schedule, and the other 2 days are reserved for continuity clinic, grand rounds, and didactics. Here is what a typical day looks like for me on this ECT elective:
7:30 AM to 11:30 AM
I arrive to the ECT procedure room just before 7:30 AM to meet the ECT team of the day, which consists of 2 CRNAs working under an anesthesiologist, an ECT technician who helps with the treatment, and the attending for the morning. On the first day of the elective, the attending orients me to the steps of the procedure and initially has me observing the treatments. However, after only a few treatments, the attending becomes the observant and allows me to lead the procedure independently, only stepping in if needed. Prior to each patient’s treatment, I review the medications for the procedures, including sedative and muscle relaxants, with the CRNAs. Once the medications are verified, the ECT technician will bring the patient into the procedure room, where the treatment will start. As the physician of the team, I am responsible for making important clinical decisions, such as checking to see if the patient is relaxed enough for stimulation, monitoring the EEG to determine if it is necessary to terminate a seizure, and deciding if any additional medications are needed to control the patient’s blood pressure or agitation. On a typical day, there are 15-20 patients scheduled for treatment, with each treatment taking about 15 minutes. In between treatments, I may get paged by the pre-op team for various needs, such as consenting a new patient or managing a patient’s agitation or anxiety. The responsibilities of leading the treatment team may seem daunting at first, but everyone on the team has had experience with ECT and is willing to help out with any questions or uncertainties. Again, the attending is always available to step in if needed.
11:30 AM to 1:30 PM
After all treatments are completed, I take a moment to complete any documentation and make sure that everyone in the PACU is recovering appropriately. I am usually able to take a one-hour break for lunch. Every Wednesday, there is an ECT team meeting between 12:30-1:30 PM to discuss any issues or updates that have come up for patients. I may also use this time to do chart review on any patient consultations that are scheduled for the afternoon.
1:30 PM to 5:00 PM
Afternoons on the ECT elective are very flexible. There may be outpatient evaluations scheduled, referred by outpatient psychiatrists, both internal and external to the university, to determine if ECT is an appropriate option for the patient. There may also be inpatient ECT consultations requested, either by the consultation-liaison team for patients who are on the medical floor or the inpatient psychiatry team. If there is no evaluation or consultation scheduled, the attending typically gives a lecture to discuss topics relevant to ECT or review reading materials that were assigned. Both patient evaluations and lectures usually end by 4:00 PM, and I use the remainder of the afternoon to complete my note, catch up on readings, or just finish the day early and relax.