For Residents

Career Choices: State hospital psychiatry

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Editor’s note: Career Choices is a new feature of Residents’ Voices. It features a psychiatry resident/fellow interviewing a psychiatrist about why he (she) has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths. Future installments will feature interviews with psychiatrists who have focused their careers on consultation-liaison psychiatry, academic psychiatry, rural psychiatry, and other career paths.

In this first Career Choices, Cornel Stanciu, MD, talked with Samantha Gnanasegaram, MD, a state hospital psychiatrist at New Hampshire Hospital, where she treats severe and chronic mental illness and testifies in various court proceedings.

Dr. Stanciu: What made you choose to become a state hospital psychiatrist?

Dr. Gnanasegaram: When I started thinking about career options after residency, I knew I wanted to start my career in a facility where I could be challenged, remain up-to-date with the most current evidence-based literature, and have the support and mentorship of seasoned psychiatrists in the field. The opportunity to work under the auspices of a great academic institution with the “bread and butter” of psychiatry reminds me every day why I chose the field in the first place. The often chronic and sometimes refractory cases I encounter daily are extremely thought-provoking, and they motivate me to think and pursue more complex management options. [This setting] also enables me to work closely as [part of] an interdisciplinary team with nursing, social work, and recreational and occupational therapy in ensuring these individuals get the best care and aftercare plans.

We often forget that psychosis often takes weeks to respond [to treatment]. Unfortunately, often in private hospitals, the longer stays that are necessary for patient care are not always possible, leading to premature psychotropic changes and discharge. In this setting, I am able to practice medicine based on what is best for the patient from an evidence-based standpoint. Additionally, being in the state system also allows me to learn first-hand and work closely with the legal system in this state and to testify in various settings to ensure my patients get the best possible care.

Dr. Stanciu: How did your career path prepare you to become a state hospital psychiatrist?

Dr. Gnanasegaram: During my residency, I had exposure to the affiliated state psychiatric hospital and spent some time on various units, each geared toward different patient populations. I also became very familiar with a wide range of psychotropics, ranging from first-line to second- and third-tier medications, as well as off-label. The ECT exposure as well as Crisis Prevention Institute training in how to deal with violent and aggressive individuals certainly added extra layers to my proficiency.

Dr. Stanciu: How would you describe a physician who is well-suited for such a setting?

Dr. Gnanasegaram: This setting is great for someone who likes to be challenged and stay current with literature. Furthermore, this is a great setting for those who are comfortable with the use of medications such as [clozapine] and long-acting injectables, and procedures such as ECT. Additionally, an ideal candidate is someone who understands the chronicity and complexity of mental illness, and has the patience to follow the course and does not rush to make drastic changes or panics at the first sign of a patient taking a step back.

A good candidate also should be comfortable with medical comorbidities, because severe mental illness often leads to poor self-care, diabetes, hypertension, etc., and should be able to work effectively in a team setting and interact with other specialties. State hospital physicians need to be cognizant of outpatient resources available to prevent decompensation in the community and not only focus on acute stabilization. Additionally, this is a great setting for those who enjoy working in an interdisciplinary team and learning from the expertise of different members of a treatment team.

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