Stephen: What first interested you in the Bellevue externship?
Liz: I was very interested in getting more experience in a hospital setting with more acute populations than we have any exposure to … I basically wanted to be able to do quick assessments as well as get a large exposure to acute population. And that happened on the first day.
S: So you were just thrown right into it.
L: Right into it. For sure.
Ali: You’re in the nurse’s station, and the patients are outside, and so you’re really there in total immersion.
L: It’s immersion with supervision, which is the best part of the externship. There is amazing supervision. Any time that you meet with a patient, you do so for a certain amount of time, a very quick amount of time—say, 15 minutes. Patients present at the emergency room, the CPEP. ‘CPEP’ stands for Comprehensive Psychiatric Emergency Program, which is the psychiatric part of the adult emergency room. The nurse does a brief interview with them to determine why they’re there and then they wait around to be interviewed. Sometimes they’ve been brought in on their own, sometimes by the police. Family might bring them. They can be transferred from the regular adult emergency room. So you then interview them. Sometimes people stay over night—they can’t leave because they’re homicidal, suicidal, or psychotic, or they’re waiting to go somewhere else.
A: The CPEP also has the EOU—‘Extended Observation Unit,’ which I believe started during the crack epidemic. Because there were so many people experiencing drug-induced psychosis and were flooding the emergency rooms, they wanted the opportunity to keep somebody for observation—because they could look very different in 24 hours. So you can keep someone in extended observation for up to 72 hours without having to sign them in or send them to an inpatient unit, which gives you an opportunity to see whether it clears, particularly if it’s drug-induced. Somebody could have come in the night before totally strung out or they might be psychotic. We don’t know, because we don’t have enough information. So someone would interview them in 24, 48, 72 hours, and if it clears then they could be released without having to go through the entire inpatient process.
L: The inpatient process can end up being days or weeks. Also, if someone is suicidal and stays the night, they might be able to leave the following the day. So you’re interviewing people at different points. With every time you interview them, it lasts about 15 minutes, and you have to gather all of this information. The cool thing is that you’re never alone. The second you complete the interview, you present the information to the attending doctor or psychologist.
S: So your role is more of a front-line person, collecting information and being with the patient and then bringing it to your team.
A: Your attending psychiatrist, if you give him a presentation, and they hear someone like—say they think what might be happening is related to drugs, maybe a contraindication—they’ll send you back to ask specific questions. You have to get comfortable not knowing and comfortable going back and forth. A lot of times, the nurses and the technicians know the patients the best … so [they] have a lot of information that can help you figure out how to approach a patient.
S: How did your roles differ from the other personnel on the floor, like the interns?
L: The interns would be doing a year, and so they would also be doing a rotation at the CPEP for a certain amount of time.
A: They might spend part of their day on CPEP, and then spend their afternoon seeing patients in the child and adolescent clinic or maybe running groups in the inpatient wards—all as part of their internship year.
L: My job this summer was different than the other externs. Instead of working the emergency room like we were just talking about, I was there in the mornings, but then I worked with the outpatient clinic in the afternoon. After patients are discharged from the CPEP they are given a Crisis Clinic followup appointment. They would then go on their own volition to the Crisis Clinic. They are then seen for about six sessions, and we [could] help them get hooked up to referrals for longer-term treatment. Sometimes, they’d go right back to the emergency room. They might become actively suicidal or psychotic during an outpatient appointment, which happened a bunch of times. It was very interesting because I got to see people over longer periods of times in less acute states.
A: Most of the externs have Crisis Clinic shifts. I did some, but most of my time was in CPEP. If I had triaged someone in the emergency, then I might want to sign them into my Crisis Clinic shift for continuity of care.
S: Was that practice encouraged?
A: Yes. Same thing with Mobile Crisis. There’s a Mobile Crisis van and a Mobile Crisis Unit. You might have a homeless schizophrenic come in and then be treated and released. They could miss their Crisis Clinic appointment, but due to high-risk or medium-risk, you might send Mobile Crisis out … I could go on Mobile Crisis to go visit the person at their shelter or home for even more continuity. … You could learn more from someone’s apartment than from many interviews. …
S: The externship sounds so stimulating, but also it appears to come with a very high degree of intensity.
A: It was exhausting.
L: You don’t have many breaks. For the three months of the externship, for three days of week, you get one week of vacation.
A: It’s a very serious experience. You are part of the clinical team. You’re not getting paid. The hours are long. It was challenging. Initially, I was physically exhausted. I think it was from being alert so much. One of the things they say to you during the beginning of orientation is that the level of alertness that you need to have while you’re there is the kind of alertness you would have in a dark alley in a bad neighborhood late at night. There are aggressive clients that can be assaultive and you need to stay watchful.
L: Patients who have attacked staff. There are take downs.
A: Then the pace could be very stressful, navigating going from meetings, interviewing, writing notes, going, doing all of that was challenging. But within a month or so, it was taking me less time to write reports, and that was making it easier to get to the next thing. And I felt more confident in the interviews. Still it was exhausting on so many levels.
S: How did you as an individual deal with that?
L: There was a certain point in the summer where I started to gain more competency and assurance in what I was doing. I could look at a chart for about three minutes and then go sit in a room with someone. And I eventually felt confident that whatever was presented, that I could get the information. And on top of that, I started to feel excited with each new person, and that I was lucky and thankful to be having this experience. And one of the things that I started to feel really good about was being at City and proud of the training that we’ve had. And so that was a good feeling.
A: We shined in the Crisis Clinic. I felt like I shined in the Crisis Clinic supervision because I was able to think about dynamics and be able to articulate clinical thinking.
S: Liz did her internship after second year and you did your after your third. How do you feel that it might have been different for you?
A: I wish it had done it earlier. I think it would have been helpful to have some of those experiences, like learning how to synthesize clinical material, before I even did my intake. They teach you mental status exams in a very significant way. You’re doing it 5 times a day. So you know what’s in a mental status, like eye contact and affect and other things. Now, writing an intake report feels like a no-brainer. Bellevue teaches you about writing a formulation that is bio-psycho-social, what is going on in their body, their mind, and their environment and what we’re going to do. I wish I had had that kind of facility earlier.
S: And how do you feel about doing it after second year?
L: I feel like I wouldn’t have been ready to do it after first year. Second year feels like a perfect time to do it. If you’ve had other training experiences previously, then maybe after first year would be appropriate. Experience helps. You have to be able to let go at the end of the day, come home and do what you need to do to relax.
A: At the beginning of the Bellevue, I felt like I had to be on top of everything and take the next triage. In the end, I knew that another shift was coming on and that if you have to go, then don’t take the next triage. They expect you to take care of yourself. No one is going to remind you to take lunch.
S: How has your clinical thinking evolved because of the Bellevue experience?
L: It has expanded greatly. My confidence has changed like night and day. I really feel much more confident to be in a new clinical situation and hold my own. It’s very different than being a therapist in a long-term treatment. That’s not something you get at Bellevue. But being in my fellowship [this year at City Tech], I feel more professional. Seeing the range of experiences and surviving these very intense interactions with a severe population put things in perspective. I feel so much more confident handling crisis situations.
A: Diagnostically, I’ve grown so much. I know what mania and psychosis look like. I know what Axis II looks like and feels like. I know the difference between a delusion and a hallucination. I have a sense of what a malingerer feels like. You just get a comfort level diagnostically.
L: Also, in terms of assessment, you write so many notes at Bellevue. At my fellowship, I wrote daily notes and they take 5 seconds. You don’t worry about that any more.
A: Also, I feel like I’ve changed my thinking about medication because you really see that not everything can be dealt with dynamically or can only be dealt with dynamically after a patient has been medicated appropriately. If someone has OCD and its at that [emergency] level, then they have to be on a medication that provides them with a certain amount of relief before you can look at the dynamics of it together.
L: Another thing that I got from working at the Crisis Clinic was learning how a short-term model could be extremely effective. I had many patients over the course of the summer that I saw for six times. … The long-term treatment model can be overwhelming for some people, and to have a short-term experience to focus on something specific and also have it be a primer for them to see the things that they might need to work on.
S: What was your favorite part of the Bellevue experience?
L: I think for me it was all encapsulated in the patient’s that I worked with. My favorite experience was with this woman that I saw six or seven times. She was a paranoid schizophrenic … It was so fascinating to work consecutively and develop an alliance with someone who had severe paranoia and learning how to be gentle with her. So it was also so challenging. We really developed a wonderful relationship in which I felt like if I could work with getting a paranoid schizophrenic—who does not understand she has schizophrenia and does not believe she is paranoid—to come to treatment and to learn to trust and piece apart her worries, that was the greatest gift given to me all summer. All the patients were such a great gift. I think about her a lot.
A: One thing that was helpful and one of my other favorite parts was case conference. One day a week on Monday’s there’s a case conference where all the trainees across levels would sit in a room and one of the psychiatrists would interview a new patient, a triage, that they didn’t know. They would interview them in front of us. The patient had to be willing to be interviewed in that setting. But you got to see their different interviewing styles, and they were in the same experience as we were. We had live supervision where two externs and whoever supervises them would watch you interview a new patient. And that would rotate. The case conferences were opportunities to watch our supervisors— they didn’t ask every question and their patients did wild things. It really leveled the playing field in a certain way, and you got to learn from different styles.
L: And it really was wonderful in ways to the see the edges of what the mind can do. I remember Steve [Tuber] once saying during our Child Practicum last Fall, when I was thinking about applying, that in order to understand children you have to see psychosis.
S: What was your least favorite part of the experience?
L: There were some power struggles that went on between the doctors and psychologists and the externs. You had to have a pretty strong core to not let it rock you. Some people buckled under that. You had to be able to take criticism and listen.
A: Like, “How come you didn’t you ask that?”
L: And I was like, “I don’t know, that’s a good point.” You have to be able to just forget things and move on. That was hard. You had to learn to be vulnerable.
S: And you, Ali?
A: My least favorite part … I think I got the most rattled by the timing and thinking that I was going to get in trouble for not finishing things. I made a mistake. They said it was like an 8:30-4:00 gig, so I actually made appointments with patients at the clinic afterwards. I boxed myself into a tight time frame. Sometimes if I took a triage in the afternoon, it might be 20 minutes and sometimes it opened up and blossomed into this thing where you were calling 10 different places and you were on the language line. I was always anxious that I was going to miss my patient. … If I had known to carve out some time, until at least 5:30, then I would have been less anxious and been more comfortable with the afternoon triage.
S: The last thing I’ll ask is: what advice would you give to someone considering applying to Bellevue.
L: It’s a fabulous experience, and I would recommend it to everybody. You have to be ready for a really hard summer. You don’t really get a summer, so that’s something to think about for self care. I think my Fall is more stressful now. I took my vacation before the externship started and a week right before school. That’s not enough. And so I think I needed more time to chill out. That’s definitely something to think about. Financially it’s very tough as well. You have to have other supports in order to take out more loans or do whatever you need to do.
A: You cannot work and do Bellevue.
L: You have to be ready to devote your summer to it and to not be able to spend the time you would want with your patients. I saw two patients over the summer and I saw each of them once a week. I decided not to do twice a week and instead do a phone session. … I think the experience is invaluable but it’s not for everyone. You have to weigh the pro’s and con’s.
A: You also have to weigh out whether temperamentally you can handle it. You have to be able to handle stress well. I often saw people getting taken down or having alcoholic seizures and people fighting. You’re in a locked ward. You’re locked in with very volatile, unpredictable people. If it’s not something temperamentally you feel like you can tolerate, then you shouldn’t pursue the externship. …
L: It’s not for everyone and that’s ok.
S: It sounds like it’s rounded out your experience and it’s worth considering. … Thank you very much for sharing.