Crack pipe mommy.

I just totaled up my hours for the week and all I can say is; wow. It has been a long week but I have learned a ton and loved the things I have been able to see and do. I am on labor and delivery and I have assisted, done / participated in many new lives making their debut into this world. I have become very comfortable with how to deliver a baby in normal conditions and how to precede in emergency / difficult situations. 

The patient population I am dealing with are poor and living in some difficult situations. Many of these mother do not have any prenatal care and they show up to the hospital for the first time when the contractions start or their water breaks.  I have had several mothers who drink, smoke and use drugs regularly during their pregnancy making it difficult for the fetus to grow and develop properly. It is hard to see these situations and not become frustrated or angry. I try to remind myself that I am not there to judge and I have no idea what their lives are like or the kind of problems they have had. I am there to provide treatment and care for the mother and the fetus.

Last night I had the emergency department (ED) ob/gyn pager and at about 6:00 pm I was paged to the ED for a trauma that involved a pregnant women. I grabbed the ultrasound machine and a senior resident and we went down to the ED to assess the mother's condition and see how the fetus was doing. All we knew about the case was that she was 6 months along in her pregnancy and had been involved in a fire where she had 3rd degree burns over her head, neck, chest and abdomen. As we approached the trauma room we could hear the high pitched screams of a female ringing out. It sounded painful. I could not imagine what I was in for as I entered the trauma bay. There was a 27 y/o African American girl lying on an exam table screaming as several other doctors and healthcare personnel scurried around trying to do their specific tasks to care for her. Someone was putting in an IV and administering her pain medication and IV fluids while others were cleaning the burns and deriding the melted flesh. My senior resident announced our presence and who we were and we started in on our job. I began firing up the ultrasound and asking her questions about her pregnancy.

"How far along are you?" "I do not know" was her response. "Have you had any prenatal care up to this point?" "No" she muttered. I continued to ask her questions while y senior resident started a vaginal ultrasound to assess the fetus. We were able to determine that this was her 7th pregnancy and all the other babies had been with different fathers and were now in the custody of the state. She did not know who the father of this baby was and did not want the baby. She had been using marijuana, cocaine, heroine, tobacco, alcohol and some other drugs throughout this entire pregnancy. The fire was caused when here crack pipe exploded setting her chest on fire. It did not sound like a suicide attempt but rather an accident while smoking crack.

We were able to determine that she was 26 weeks into her pregnancy and that the fetus was alive. We hooked her up to a fetal monitor that we could monitor from the L&D floor while they finished taking care of her burns. It did not look like she was in risk of going into early labor. We monitored her the rest of the shift and the doctors on the next shift were introduced and continued to monitor her and the fetus. 

I have had several drug abusing mothers who are pregnant and continue to use their drugs. It is always a sad situation. I have to remain focused on patient care and education while trying to not judge the patient. This patient will most likely live for now and will go onto to deliver an infant who has brain damage and other abnormalities due to the exposure to drugs while developing. The most common drug and often the most dangerous and damaging of these substances is alcohol. 

There is not a lot of time to worry about the controversies of hysterectomies while working like this and trying to care for these patients. 

Labor and Delivery

This whole week I have been working on the Labor and Delivery during the day shift which runs from 6:00 am to 8:00 pm and it usually takes a while to sign out to the night team. My job is to basically assist the residents and attending doctors get things done. As I was able to demonstrate my competence in certain procedures I was allowed to take on a more active role. The director of the L&D unit is a big proponent for vaginal delivery and we work to do all deliveries vaginally if it can be done safely. So I was able to help in many vaginal deliveries and I actually got to deliver several babies this past week. I was also able to assist in a handful of c-sections that were considered necessary or emergent. The c-section vs vaginal delivery is another point of controversy in the field of ob/gyn. 

We had one patient this week who presented at 22 weeks with a complaint that she no longer felt the fetus moving. Upon ultrasound we were able to determine that the fetus was not going to survive and the mother was going into labor. I sat with the mother her husband and her mother to discuss the diagnosis and they of course were devastated at their loss and overcome with grief. I answered all of their questions and provided them with as much information as possible. Later in the day we had an active drug abuser mother at 39 weeks start to push and go into the final phases of delivery and everyone quickly scrubbed in to deliver the baby. Another student was allowed to scrub and assist in the delivery so I was not directly involved. The delivery became complicated and more physicians were paged to come and help with the delivery with the hopes of avoiding a c-section. It became very intense and complicated and one of the doctors asked me to page for some back up blood. I left the room to take care of the back up blood. 

On my way back to the room where the delivery was occurring the grandmother of the the women who had the 22 week old dead fetus came into the hall way and yelled to me please come quick my daughter wants to push. I yelled to a nurse to get one of the physicians to come and meet me. I entered the room and the mother was starting to push out the fetus. I tried to tell her to wait and stop pushing as I quickly put some gloves on but she kept pushing. I arrived in time to catch the entire placental sac and fetus. I kept it guarded from the mother as she had said she did not want to see it. Once I got it completely out I took it to the adjoinging room with the infant warmer and cut the sac to deliver the fetus. At this point a bunch of physicians had arrived to take over and run the show. I was able to follow all of my training but I was certain upon seeing the fetus that it was dead and had been dead prior to the delivery.

It happened so quickly that I did not have any time to process it. The family was of course very upset and crying and as the other doctors took over I was able to go back to the family and sit with them and try to comfort them. They wanted to know the sex of the fetus but did not want to see it. I told them it was a boy. 

What an intense experience and it did not hit me until I was driving home late that night. I nearly broke down as I thought about how difficult it was and how fragile life is. 

Comments on Hysterectomies

So my little blog recently exploded with hits and web traffic after I posted about hysterectomies. If you have been following this blog I am sure you are aware of the recent comments and discussion that occurred. It has been extremely interesting to say the least. However controversy and medicine is not a new phenomenon. There are many different issues that spark religious like passion and discussion. Just to name a few; immunizations, silicon breast implants, psychiatric medications, blood transfusions, hysterectomies and I could go on. 

I decided to sit down with the chief of ob/gyn at my training center and discuss hysterectomies and and the history of ob/gyn. Needless to say it was very enlightening and interesting. I had forwarded him my blog address so that he could read the comments prior to our meeting. He has been practicing ob/gyn since 1974 and has served in many leadership roles and faculty positions with in the community of women's health initiatives. He was able to shine some light on many aspects of ob/gyn and women's health. 

One of his interesting and profound statements that he made was that as a doctor you can't focus on anything other than the patient you are treating at the moment. You have to put aside your views, your opinions, your ideals and really focus on what is best for that patient. Any time you make blanket statements or decisions you will run into trouble. For example you can't think "Every women with disease X should get procedure Y". You also can't say patient X had a bad outcome with treatment Y so this treatment should be thrown out and noone should ever get treatment Y again. Every patient is so different and unique that they have to be approached in an individual custom process.

I asked him about his opinion of hysterectomies and the controversy around the procedure. He said that it is his policy that surgical intervention should be the last option after all other options have been attempted. He said his biggest challenge is that he spends much of his time trying to talk patients out of getting a hysterectomy but that many patients have friends and relatives who loved their results and they want instant gratification and really push for the procedure. He said he has had several patients that he tried to sway from a surgical procedure ultimately go to a different doctor and twist their arm to do the procedure until they were able to get it done. He also said that there is definitely a need for hysterectomies in the right patient. He explained that there are certain patients with disease that would benefit from hysterectomy and if the physician failed to offer the procedure he would be negligent. 

He explained that he has never lost a law suit and has been sued very few times compared to the normal ob/gyn doctor. He said he has been sued 4 times for not performing a hysterectomy and has never been sued for performing a hysterectomy. It has been his experience that this is a common phenomenon. An ob/gyn is more likely to be sued for not performing a hysterectomy than for performing a hysterectomy. He also explained that because reimbursement is dropping that ultimately a physician is better compensated for managing the patient medically than performing the surgery. Many of his patients will try medical management but ultimately give up with frustration and ask for the hysterectomy. We chatted for a long time on this issue and I do not have time to include all of the information. It is a complicated issue that involves many aspects. 

He will allow me to call any of his patients and ask them about their experience with their hysterectomy for the purpose of my learning. I am developing a survey to use for this purpose.

Thanks to all for your comments.  

Edit after some comments: There is no way I have time to list and write out everything that was discussed at my meeting with the chief or ob/gyne and the other doctors and patients I have talked with at length however I can tell you we discussed everything that your comments have mentioned. I also have the copy of our consent forms and I am not allowed to post them I can tell you they cover many of the issues mentioned like loss of orgasm in some woman and loss of libido in others and the health risks. 

The Dark Side of Hysterectomies.

I have had a ton of comments and emails sent my way from various readers who are mostly upset. Rather than reply individually to each one I thought I would make a post to make some general responses. For some reason some of the comments are not showing up o the blog but I am getting them via email so I will try to address those comments as well.

First of all let me start off by saying I am not pro-hysterectomy or trying to push hysterectomy on anyone. All of the procedures I have been involved with have been part of my training and would have been done wether I was there or not. I certainly did not have the lead role but mostly an observatory role and some minor responsibilities like suturing etc. 

What are the comments? Many angry, upset individuals have emailed me with their concerns about hysterectomies. These are patients who expressed their feelings that they were mislead by their doctors and forced into getting a hysterectomy. Now they suffer the side effects and are upset with the results. Most of the complaints have been focused on the sexual side effects and they compare it or call it castration. I certainly feel bad for any person in this type of situation and I do not support or condone mistreatment or patients of any kind and would never willingly participate in any such activities.

Currently I am training at a non-profit center that is subsidized and no doctors are paid on an incentive base plan. This means that the doctors get paid the same wether they do 1 surgery or 10 surgeries in a day. All of the patients are considered charity cases and none of them are asked to pay for these services. Some may have public aid that will pay in some cases a very small fee if any payment at all. I can definitely say that the doctors I am working at are not doing hysterectomies to make extra money as they do not get paid extra for doing extra cases and 90% of the cases are done free of charge. Most of the funds to keep this center open come from donated funds, subsidies and volunteered time by service doctors and nurses

I chose to train at this incredible center knowing that it was mostly service oriented medicine. The patients are very grateful for the treatment they get and have ended up at this center after years of not being able to get treatment anywhere. Many of my days during this rotation are spent on running a free pap clinic, STD screening clinic and Breast clinic. We work 15 + hour days in these clinics as part of our training and truly enjoy it and feel grateful for the opportunity and experience.

I had the opportunity to sit in on several consent meetings for the hysterectomies. In the cases I was involved with, these meetings took at least 30 minutes and involved walking through the risks and answering the patient's and the patient's family's questions. At some point during the meetings there was a doctor, nurse, social worker and a  patient advocate whose sole job is to present the negative aspects of the surgery and assure and document that the doctor and others fully explained the side effects. The average amount of time that the patients I saw had been waiting for this procedure was 4.5 years. Given the nature of this "free" center you can imagine the back up of cases. Working with volunteer healthcare workers and limited resources makes the process a lengthy ordeal. In the cases I saw these patients were literally begging for the procedure. One case had to be postponed and the patient wept hysterically and believed she would never get the chance to have the procedure done. The cases I saw were all had debilitating cases and or had premalignant or malignant cells on pathology or progressed to the point where the pain was so bad that the patient was on disability and not working. All of these cases had received multiple years of non-invasive medical treatments prior to this surgery. I am not saying that this is how all the centers work or operate or denying claims made in any of the comments.

I am not claiming that the cases presented in some of the comments do not occur. I am just saying they are not occurring at the center in the few cases that I have seen or been involved with. 

I also have seen and treated several cases at this center on my gyn oncology rotation of stage 4 terminal ovarian, cervical uterine cancers that were in patients who were never able to get a hysterectomy or had a partial hysterectomy and left the ovaries behind. In most of these cases a hysterectomy had been offered at some point in the patients lives and refused for a number of different reasons. I held the hand of a dying mother and her son's hand as she died in his arms. She had ovarian cancer that had formed in her ovaries that had been left behind at her request from a previous hysterectomy. The son is filing a lawsuit on the doctor who left the ovaries behind for not "forcing" (his words) his mother to have the ovaries removed. 

I have no intention to become an OB/GYN doctor. Mostly for personal reasons it is not the field I will ultimately go into. 

My blog is a blog intended for my families and friends who want to read about my training process. It is not a political statement of any kind. There is no intention to sell or preach any given procedure or medical ideal. My long term goal is to ultimately serve medical missions inside and outside of the United States.

Thank you for all of your comments and sharing of information. Certainly the kind comments were better received. Comments like the one provided by the president of the HERS Foundation are informative and appreciated. The accusatory and angry comments by some that can be read under the comments on my blog, come across cheapened and fanatical even if the information was good. The tone of some of the comments (not all) clouds the message and discredits the author. I understand this is an emotional topic for those involved. 

I will gladly provide educational material about the negative sides of hysterectomies and other medical procedures. I feel it is my duty to do so and serve as apatient advocate.

I encourage all to read the comments and will more than happy to post relevant information. If people have trouble accessing the comments I can post them as well. Many came to me through email but did not show up on the blog. However the comments that did show up are a good representation of many of the comments I received. There were a handful of death threats and over the top angry comments that were not posted as well as they came directly rather than appearing on the blog.

Another option for hysterectomy

I had a really long day on Friday. I was in surgery so that was exciting. We did 3 vaginal hysterectomies. These are difficult because you have to operate through such a small area. The nice part for the patient is that they do not have any surgical scars when the operation is finished and the recover time is significantly less given the non-invasive procedure. 

The downside for the doctor is that it takes a long time, much longer than an open hysterectomy and there is an increase risk of cutting a ureter given the lack of space makes it difficult to see all the anatomy clearly. 

I arrived at the hospital at 5:00 am and left at 9:00 pm with a 1.5 hour commute each way it was a 3:30 am - 10:30 pm work day = 19 hours. Talk about tired. Fortunately you have so much adrenaline going during surgery that you do not feel the tiredness during the procedures. However about half way home the fatigue hits me like a brick wall and I have to hang on until I get home before collapsing. I should have studied for the exam at the end of the rotation but there was no way to do any studying in the dismal state of fatigue.

Gynecology = Surgery.

Friday I was able to help with surgeries all day long. I like the operating room. There seems to be no concept of time in the OR. You are not watching the clock, you forget about hunger or using the bathroom. When you finally do glance at the clock you realize several hours have passed in what seems to be a blink of your eye. There is this unexplainable sense of confidence in the air. That being said there is also the long hours and the unpredictability that goes hand in hand with surgery specialties. Sure you get to be the big man / woman in the OR but that is about the only place. You are a stranger at home, a memory to your children, and an ex-husband or ex-wife to your former significant other. 

I was able to help on a laparoscopic hysterectomy with preservation of the ovaries. It was a sad case. The patient was a 39 year old female (obviously) who never had a chance to have children. She had symptomatic uterine fibroids that had plagued her most of her menstruating life. Finally she had had enough and wanted the surgery. In this surgery 3 small holes are made in the abdomen / pelvic area. Through these incisions a camera and surgical instruments are passed to perform all of the work. You also have to fill the abdomen with air to open up the space so you can see and have room to work. 

The biggest risk with the removal of the uterus is the potential for massive hemorrhage. When a woman dies in birth it often was caused by massive hemorrhage of the uterus. The uterus has a large number of vessels that vascularize it and keep it healthy and well nourished. Most of the surgery is spent cauterizing vessels feeding the uterus. You do not want to miss any because this can cause serious bleeding when you pull the uterus out. My job was to hold and maneuver the uterus to help the other 2 doctors to find, cut and cauterize all the vessels. I accessed the uterus through the vagina. It was demanding to hold the uterus in the correct position and if you were to let it slip you run the risk of tearing a vessel that had not been cauterized which would cause massive hemorrhage. By maneuvering the uterus I could expose certain vessels that could then be cut. The patient's uterus was so diseased it was very large, about the size of a 16 week pregnant uterus. 

It took several hours to tie off all the vessels and then remove the uterus and cervix through the vagina. It was so big it seemed like delivering a small baby. This was a fascinating surgery. Many surgeons do this surgery open, meaning they cut the abdomen are completely open to expose the uterus. An open surgery is quicker and easier to preform but leaves the patient with a long recovery time and weakened abdominal muscles and a large scar. Laparoscopic is the way to go if possible. 

We did another surgery where we used a CO2 laser to ablate non-cancerous lesions off of a patients cervix. It was cool to use laser technology and the surgery was fairly simple and done with only an epidural and no general anesthesia. So the patient was awake through the entire surgery. There was no cutting involved. We simply exposed the cervix through the vaginal opening and removed the lesions with the laser. We had to wear protective goggles to avoid damaging our eyes if they accidentally entered the path of the laser. 

The final surgery we did was an open abdominal hysterectomy where the entire tract was removed; cervix, uterus, fallopian tubes and ovaries. It took less time than the laparoscopic surgery. It was also easier to see all the anatomy which meant the attending grilled me with a ton of questions. "What is this structure?" "What never innervates this structure?" etc. Some attendings will kick you out of the OR if you miss too many of the questions. Fortunately I had brushed up on the anatomy so I was ready for the pimping! 

Pimping is a term medical students use to describe the process of being asked questions in a quiz/test like manner by residents and or attendings. It is a common practice in our training and a crucial part of our learning. Some dislike being put on the spot in front of everyone but I think it makes you prepare more thoroughly. SOe doctors will continue to ask harder and harder questions until you finally miss one and then tell you that you do not know anything and are a disappointment. You can't take it personally and have to understand it is just part of the process. Other doctors are very nice about it and do on the spot teaching with each question. 

Why become an OB/GYN doctor?

I just finished my first week of OB/GYN and I have been on the Gynecology service all week. This means I was mostly in the OR helping with a wide variety of surgeries. I got to help on several hysterectomies, ovarian surgeries, fibroid removal. Basically any disease of the female reproductive system besides the cancer we were in charge of handling. Next week I will be on GYN/oncology and will handle all the cancer involving the female reproductive tract and often these will be terminal cases. 

Being in the OR reminded me of how much I like doing surgery but I also realized that the lifestyle is not worth the thrill of the OR. The hours are completely unreliable and inevitably long. I have been working 16+ hours again all week and I am required to work weekends as well. These long days ad up quick and when you realize the residents work like this and the attending's hours are not much better, it is easy to determine that the surgical specialties are not worth the life commitment. 

I once had a surgeon tell me in all honesty "If you want to be a good surgeon, you must be a surgeon and it must encompass your whole life, you will no longer be a father, you will no longer be a husband, you will have to drop your religion and everything else you knew about your life. That is what it takes to be a good surgeon." he explained. This is obviously a little extreme and not every surgeon is like this, but I know a few who would not claim to be this way but when you look at their lives you would see that they really have become engulfed in the surgeon life and everything else has fallen by the wayside.

Why am I talking about surgeons if I am doing OB/GYN? The field of OB/GYN has always been considered a surgical subspecialty. A lot of people are attracted to OB/GYN who really liked surgery but also loved the medicine side of things as well, like managing illnesses that do not require surgery. In the past 20 years OB/GYNs have also become primary care doctors for many women so they manage all the health issues of the female patients they have in their practice. In addition to the medicine side they get to go to the OR a few times / week and perform surgeries. Many of these surgeries are complicated. If you want to do surgery but you do not think you can give up the medicine side, OB/GYN may be your calling. Not to mention you get to deliver babies as well. 

I do not have any desire to do OB/GYN as my choice of specialty but I can see why it appeals to some. 

Psychiatry Shelf Exam and Grades.

I have had today off to study for the psychiatry shelf exam which I have tomorrow. The shelf exams are national exams that most medical students in the USA are required to take at the end of their rotations. The can be pretty tough and have some obscure case scenarios. 

A lot of medical students complain about the grading during their 3rd and 4th year rotations. It can be very subjective and not as straight forward as the first 2 years of medical school courses. At my school you are evaluated on a clinical level and then on exam knowledge level as well. There are 6 categories that your attending physicians rank you on according to their opinion of your performance. We are ranked on Knowledge, patient care, professionalism, life long learning, inter-professional practice, communication. You can get an outstanding, good, adequate or inadequate for each of the categories. In order to get an A you need 3 of the 6 categories to be ranked as outstanding and you need to get .25 standard deviation above the national mean on the shelf exam. You have to meet both these requirements to get the A. If you get the outstandings but not .25 standard deviation above the mean you will not get the A. If you get .25 standard deviation above the mean but not 3 or more outstandings you will not get an A.

For the students who are very good at studying and taking exams usually have no problem getting the score on the shelf exam but they tend to not do as well on their evaluations so for the first time in their lives they get a B and are furious. Those students who are better on a social level tend to do well on the evaluations and get more outstandings but those students often have more difficulty on the shelf exam. The students who can succeed in both areas get the A. As you can imagine the evaluation aspect can really depend on the doctors giving you the evaluation. Some doctors refuse to give above a good for anyone and other doctors may mark all outstandings without much thought. All of the evaluations for a given rotation are averaged to determine your final evaluation. 

I have found it helpful to actually sit down with those doing my evaluation and explain the system to them and ask them to mark outstanding if they think I did "A" level work. This method has proven to be effective. You have to ask for the business. Your average medical student would never even think to do this. A little bit of life experience goes a long way in these kinds of situations. I am pretty sure for my psychiatry rotation I have the outstandings taken care of so now I just need to do well on the shelf exam to get the A.

Put a fork in it. It's done!

Today I finished my last day of my psychiatry rotation and I have to say that I am a little sad to have it end. The lifestyle has been great. Basically I have been able to see my patients in the morning and meet with my attending physician to make my recommendations and medication changes. Then I would go to lecture and call it a day. Easy, low stress and not too many hours. I think many people are attracted to psychiatry because of the lifestyle, ie less hours and less stress.

Today I had 2 patients that I was planning on discharging. A 34 year old many with schizophrenia paranoid type and chronic marijuana use who recently missed his 2 week injection of antipsychotic medication. Within a week of missing his medication he started hearing voices and became more and more psychotic until he brought himself into the ER because the voices were telling him to hurt himself and his mother. We got him back on his medications and over the course of 6 days saw him go from crying and psychotic to smiling and nearly normal. He tends to get healthy and then let his medications slide and use more marijuana until he has a psychotic break and needs hospitalization. Today he was doing great and ready for discharge. I wrote him his prescriptions and got his outpatient appointments set up through the social worker and sent him home.

The second patient was another schizophrenic patient who had been improving but decompensated  yesterday when she grabbed her nurses breast and twisted it clockwise and then kicked her in the crotch. I hate it when that happens. Why did she decompensate? It was curious to me that she had improved so much over the course of the week and then suddenly became aggressive and psychotic again. I asked the nurses and read some of their notes to try to see if anything stuck out as a reason for her getting worse. I soon realized that my patient had the same last name of another patient on the unit and one of our nurses gave an injection of a medication for the other patient to my patient. This was a medication that last a month and was not meant to be given to my patient. 

Once I found this error it all made sense to me. My patient had become worse because she was on a medication that she was not used to and the feeling worsened her psychosis. I had to talk with the nurse and show her the error and also my attending physician who of course was upset. Then I had the joy of calling the patient's husband who fortunately is a physician and completely understood. Actually the medication given by accident could be a beneficial medicine for my patient in the long run but not at the dose she received. The husband was totally cool about it and when I told him what the medication was he said "well she could benefit from the medication anyways." 

The husband was very thankful for the progress we had made with his wife because he was at the end of his rope and did not know what to do and was considering putting his wife in a nursing home. She has a long history of schizoaffective disorder with mania and had been fairly well controlled for the last 15 years on lithium but recently her psychiatrist stopped the lithium because her kidneys started to fail. Kidney failure is a potential risk of long term lithium use. She was switched to resperidol in December and basically spun completely out of control to the point where the husband could no longer care for her. He wanted to put her back on lithium despite the kidney failure because she was at least manageable on the lithium. He begged us to reconsider lithium but we told him we would try a couple of different medications until we found something that worked. We put her on valproic acid and amazingly she responded very well. The husband visited and remarked that she was even better than when she had been on lithium. The husband and the some were both very happy. It was great to see. 

We had her ready to go today but because of the increased aggression caused by administration of the wrong medication we decided to keep her a couple of more days until her aggressive behavior is better controlled.

I am going to miss psychiatry!

A lifetime of Psychiatry

Someone asked me the other day if I would consider a career in Psychiatry. I have always liked all things regarding mental health and since entering medical school I have considered psychiatry as a viable option. However, one of my biggest concerns about psychiatry is that a lot of the medical aspects of medical training I like so much are eroded away as you focus more specifically on the psychiatric illnesses. For example, if I mention to my attending psychiatrist that I think our schizophrenic patient may have a UTI the response will be; "Why are you telling me about a UTI that is medicine's problem not our problem we only deal with the mental illnesses." I guess any field you specialize in you will give up knowledge and skills in other areas of medicine but it seems like in psychiatry you are often caught defending the specialty as "real" doctors. 

Mental illness in the USA carries a big stigma and this stigma flows into the doctors as well. Many of the psychiatrists have told me that when they told their friends or family that they decided to go into psychiatry they sensed disappointment. On psychiatrist told me her mother cried when she told her and asked why she was not going to become a real doctor. This does not bother me so much but the field in general has an uphill battle in fighting these uneducated view points. It can be exceedingly difficult to treat illnesses that many patients and their families do not believe exist. 

There are also some turf wars in many areas of the country where psychologists are moving in on some of psychiatry's work. The psychologists are fighting for prescribing rights which if allowed could potentially decrease the value and the pay of psychiatrists in general. Turf wars are not unique to psychiatry. You have optometrists taking on ophthalmology, nurse anesthetists tacking on anesthesiology, chiropractors trying to do primary care work, and many fields within medicine fighting over certain procedures or patients. However psychology seems prone to these kinds of battles. 

There is not a perfect specialty in medicine, all of them have there strengths and weaknesses but I do not think I will end up going into psychiatry. I certainly have liked this rotation and have learned a ton. It is fascinating how fragile the brain can be and the illnesses present in such curious ways. There is nothing like treating a patient in the middle of a psychotic break.