SUNY Downstate Health Sciences University
Department of Psychiatry & Behavioral Sciences
A Day in the Life
At the start of July, I rented an off-white Suburban and drove 700 miles across the country. I watched the topography change from the flat, tree-lined highways of Michigan to the endless hills of Pennsylvania. I crammed more things in the car than I would have ever thought possible: two wood tables, an accent chair, a dozen pairs of shoes in their boxes, a pharmacy worth of over-the-counter medications. It sounds cliché, but as I crossed the Verrazano Bridge from Staten Island into Brooklyn, I really did think, “This is my life, it’s mine, and it’s starting.”
New York has that effect on people. I was predestined to love it, based on all the characters in every book I’ve ever read. Michigan has its own beauty — blues and greens, pine trees and lakes — but it lacks the culture, the fast pace, the steady thrum and magnetic pull of Brooklyn. I live in Prospect Heights, near most of my classmates, who I often see around the neighborhood. My apartment has high and, because of its huge windows, filled with light. I never saw the building, or the neighborhood, before moving in.
I matched at Downstate on March 20, 2020, in the height of the Covid pandemic. I was quarantined in my childhood home for the next six weeks. During that time, I was terrified. I was afraid to leave my family in Michigan, afraid to live in the city most affected by the virus. But New York is, I believe, the most resilient city in the world. In the months since I arrived, I have watched my neighborhood grow more vibrant each day, with restaurants spilling outdoor tables onto sidewalks and people talking animatedly behind masks. The ones who stayed are proud that they didn’t abandon their home, and the ones who left are starting to come back, to the detriment of the traffic situation.
I spend my weekends with friends and co-residents outdoors, on rooftops with views of Manhattan, in Prospect Park, or exploring different neighborhoods of Brooklyn — Crown Heights, Park Slope, Brooklyn Heights, Fort Greene. I have found my coworkers to be highly empathetic and passionate individuals. Universally, we have interests and hobbies outside medicine. There are many avid readers among us, and I have already borrowed and loaned multiple works of fiction. Some residents are incredible social justice advocates, others are experts in jujitsu, more still are wonderful bakers and cooks. Many have lived around the world and traveled widely. The diversity of Brooklyn is incredible, and the diversity among Downstate residents is no less astounding.
The true treasure of the Downstate program is the CPEP, or psychiatric emergency room. The CPEP is hectic, exciting, and filled exclusively with psychiatric patients in emergency situations. Located in Kings County Hospital, the CPEP is the largest and busiest in a city. This is where we do all of our calls intern year, and where you will see virtually everything there is to see in psychiatry. In my first few shifts, I have already managed acute mania, two child cases, and a first break psychotic episode. It is a wonderful learning environment and a place Downstate residents feel at home, so much so that we actually, uniquely, look forward to being on call. To me, the CPEP is reflective of Brooklyn itself — unpredictable, ever-changing, and enriching. However, there is also a very sobering aspect to working in the CPEP. Our patients are usually very sick and very poor. As residents, we are able to offer them something invaluable: our time and energy. I think that all of us feel the responsibility and honor of the position we are in — a position to help the patients who need it most.
What else can I tell you? I take the two train to work and back every day. I live in the moment, in a way I never have before. Always, in high school, college, and medical school, I thought of the next step. Now, I think of this. Of the way Brooklyn changes depending if I walk East or West, of my patients, of what they’re saying and what they need, of what I need, what I want, not years from now, but now, immediately. This feeling is likely unique to intern year of residency, when the current moment is mostly all we can manage. But it is also unique to New York, a city that demands your presence of mind. In this city, at this program, I am challenged. Challenged to stay present, but also challenged to become an excellent clinician.
I think for most of us who come from places like the Midwest and move to New York, this is what we wanted. For the first time in our lives, we are being asked to give all we can, to our patients and to ourselves. For me, this is a relief. I was worried no one would ever ask.
PHP and Me
Hi, my name’s Sam Jackson, and I’m a PGY-2 Resident. I’m currently rotating in the Partial Hospital Program (PHP), a stellar and unique program at Kings County Hospital, the primary rotation site in our residency and the largest county hospital in New York. Especially on this rotation, I look forward to getting up and going to work, in part because I don’t need to be there until 8:15 (which after a medicine rotation feels amazing). I get up around 7 AM, well-rested, with plenty of time to shower, eat and get ready. I live in Crown Heights, where a majority of my classmates also live, and take the bus or train to work every day, which takes 20-25 minutes. I love this neighborhood. My rent’s reasonable, there’s a really fun social scene with great restaurants, and it’s very conveniently located for most of our rotation sites.
PHP is an excellent program, I can’t say it enough, for both patients and rotating residents. For the most part, our patients are referred from an inpatient unit somewhere in the city and are coming to us for a step-down form of care, where they attend group and individual therapy for 6 weeks, Monday through Friday from 9-3 PM. Residents carry a large patient load, between 15-20 patients, but are only required to see and write a note on each patient once per week, which allows us to appreciate a wide spectrum of pathology. Residents do the intake interviews and make medication adjustments as needed, all with the supervisions of the attending psychiatrist, so it a great rotation to hone interview skills as well as learn a variety of psychopharmacology. However, the best part is that you get to interact with your patients every day for an entire month, truly appreciate their struggles, and celebrate their successes. Earlier this week, I joined an exercise group and played 3 on 3 basketball with a group of my younger male patients almost all of which recently had their first break psychosis. How incredible! There’s a sense of community ingrained in the care given in this setting that I love and hope to incorporate in my future practice. After the patients leave at 3PM, I generally write notes for a couple hours and between 5 and 6 PM. In the evenings, I like to play soccer (I try to play twice a week), picnic in Prospect Park, cook, and read (for fun and academics). Especially on the psych rotations, it’s not only possible but also encouraged to have a life outside of work.
While on psych rotations, PGY-1’s are on-call 3 times a month at CPEP (Comprehensive Psychiatric Emergency Program). Weekday night shifts are 5-9 PM and weekends are 8-8 PM. The general mantra is, if you can handle Kings County CPEP, you can handle anything. I’m new, but from what I’ve experienced so far, I think this will be true. Although I treasure long-lasting relationships with patients that form in settings like PHP, I can’t help but be thrilled by the mania and psychosis I’ve seen in CPEP. For anyone interested in psych, which I assume you are if you’re reading this, call days pass quickly because they are a lot of fun.
Also of note, every Thursday afternoon from 12-5 PM we have protected didactics – regardless of which rotation you are on. You will be a work horse at times during residency but this protected time guarantees that your training remains academic and is another gem of the program.
SUNY Downstate was my number one ranked psych program, and in the first 3 months it has only exceeded my expectations. Most of the attendings are brilliant and caring, Brooklyn is a lot of fun, and the patients have already left lasting impressions that make the idea of leaving difficult to imagine.
Starting Out: A View from Inside
My name is Mahmoud Dweik and I’m one of the PGY-2 residents here at SUNY Downstate.
Starting psychiatry residency has been a fascinating and rewarding experience. Our patient population presents us with the opportunity to learn from a diverse psychiatric population requiring a high acuity of care.
I started on the inpatient rotation on 4-West along with another resident. My days would start at around 8AM with chart review, contacting collateral, following up medication orders, and prerounding. Multi-disciplinary rounds run from 9AM to 10AM during which time nursing staff report on overnight events and treatments are discussed. Afterward, I would round on patients together with the attending and see any new admissions. Interviews are always followed by feedback on interview techniques and teaching by the attending. A few days of the week include treatment team meetings or meetings with family. I particularly looked forward to academic time. Once weekly, a resident presented an article in contemporary psychiatry followed by a discussion with the attending. Having medical students during the rotation gave me an opportunity to revisit basic topics in psychiatry and let me pursue my passion for teaching. Lunch was a regular fixture of the day for the residents. In the beginning when I was learning the EMR my day would end at 7pm; toward the of the rotation, I would leave by 5pm. Weekly supervision with Drs. Occhiogrosso and El Sara was a chance for me to really grow as a young psychiatrist, learn from their experience, and address my concerns or limitations.
I take the bus home so I usually will do my readings on the way. Once home, I take an hour to relax, call my family, play some music, or have a bite to eat. I’ve been able to maintain an active lifestyle on the rotation, weight lifting or going for a walk about 3 times a week. Weekends are free with the exception of occasional call shifts in CPEP. NYC is a very cultural rich city. I’ve had a great time exploring museums, coffee shops, and restaurants on the weekends with friends and co-residents. So far residency has been an enriching experience, I’ve learned a great deal about psychopharmacology and interviewing from a number of attentive mentors and had time to have fun outside of work.
PGY-2: Building on Foundations
Hi reader! I’m Sean Jau-Ren Yancey and at the time of writing am a third-year resident at SUNY Downstate.
The PGY-2 year at SUNY Downstate involves experiences running the gamut of psychiatric specialties: consulting on medical and surgical inpatients, risk assessment and management of patients in the Kings County Hospital Comprehensive Psychiatric Emergency Program (CPEP), time on a Child and Adolescent unit, a month on a first-break psychosis unit, Forensic Psychiatry at the Brooklyn Supreme Court, Addiction Psychiatry at the Brooklyn VA, treating chronic patients at Kingsboro Psychiatric Center, Geriatric Psychiatry, as well as a month devoted to research.
I’m currently in my second continuous month of rotating through a consult-liaison service, the first month at University Hospital of Brooklyn and the second right across Clarkson Avenue at Kings County Hospital. A five minute walk yields more than a change in EMR; it’s been edifying to learn about the significant differences between an academic teaching institution and a hospital in the largest municipal hospital system in the United States.
In any case, my day’s journey begins a roughly 20 minute walk away in my apartment at the South-Eastern corner of Prospect Park, the site of sloth-like afternoons spent reading in the shade of a tree. A sign at the entrance of the McDonald’s right around the corner says, “Welcome to Flatbush”, a predominantly Afro-Caribbean community lined with jerk chicken spots and dollar vans running the length of the major arteries of the neighborhood. This is also a microcosm of the incredible diversity in Brooklyn. I can hear Russian, Mandarin, and Creole without reaching the end of the block. I could rhapsodize about living in New York to no end because everything imaginable is here to experience. The Honolulu of my childhood exists a world away. I can’t help but to love the raw energy saturating the aggregate in a ubiquitous and undeniable mythological way. But I digress.
Upon arrival to the hospital I pick up the pager from the overnight team and head to the consult office with its faint rubber-y smell, a few densely packed cubicles that remain empty most of the day, and walls marked by the framed pastel artwork done by one of the attendings. After a brief stint of chart review I’m usually off to the medical emergency room to see a stat consult.
Naturally, the second year of training here builds on lessons learned in my first year. So off in the medical ED I’ll be tackling that first consult with a little less looking behind me for my attending than a little more intentionality fueled by a year of clinical experience, seeing patterns seen before and fueled by my own curiosity. But these are still my early days in psychiatry, so I guess I could place my current Erikson stage of psychiatric residency training firmly in the realm of initiative versus guilt.
My day proceeds by responding to various requests from teams scattered throughout the, at least according to the ‘Statistics in 2015’ blurb on the Kings County website, over 627 bed hospital. We answer questions that fall somewhere along that Moebius strip of a spectrum running from hilarious to heartbreaking. Some consults are the usual fare: capacity evaluations, delirium, self-harm, substance use, managing psychotic illness on the medical floor. But there is never a dull day. You may be called to consult on a person not admitted to the hospital. I’ve been the liaison between rabbis, patients, and families. Sometimes CL is best bluntly described as treating the anxious medical teams. All just scratching the surface on a very interesting day’s work.
In sum, the theme is diversity and training here exemplifies this. My colleagues hail from Tehran to Trinidad and our patients congregate from far and near. This special mélange helps me respect and recognize ways of being not my own. And at some level, we work in a field where we are asked to determine what’s “normal” and what’s “different”. What setting better than here in the heart of Brooklyn?
A PGY-3 Psychiatry Resident
With the requirements of inpatient out of the way, the diverse outpatient experiences one gets at SUNY Downstate are all about ample exposure. A typical day starts at 8:30 AM in Kings County with morning report, where we get together, have coffee, and discuss interesting and challenging cases with each other and different supervisors.
We spend one and a half days in outpatient clinic at the County, seeing our patients for medication management, therapy, group and family sessions, as necessary. We also have Clozapine patients who we manage. Our time in the clinic is where we get supervision on our cases, and have weekly journal club.
Mondays are divided into 6 month blocks, with six months spent at Kings County Outpatient Hospital Center doing new intakes and 6 months at the VA hospital. It is during the first six months that we take on new patients in the OPD, depending on our interests, as well as gaps in our knowledge base. The other VA hospital months are where we get exposed to treating veterans with post traumatic stress disorder, anxiety, and depression, both in the clinic setting and in group therapy. The experience is unlike any other, as there are veterans from Vietnam, Iraq, and Afghanistan, and their experiences are heterogeneous yet similar in so many ways.
My Wednesdays are spent running the CBT for psychosis group, which my colleague and I coordinate. We put it together from scratch, choosing our topic, supervisor, and the direction that it would take. It has morphed into a group for young patients with psychosis, learning new techniques to cope with auditory hallucinations and paranoia and the results have been great. The resources available to residents in the clinics are boundless, and one simply has to express interest in a topic before some one says, "I know how I can help you do that!"
Thursdays are for didactics, and it is also the day I have my evening clinic, where I have two long term psychodynamic psychotherapy patients, who I see weekly. Again, the diversity of experiences is so streamlined that it fits so smoothly with the rhythm of the week, but overall, it is fulfilling to feel that my training is well rounded.
In the meantime, as the weekend approaches, I prepare for the research that I am working on, as well as factor in some relaxation and fun time, if I am not on consult call, which as a 3rd year, does come into play 2 or 3 times a month.
The diversity of 3rd year, as well as the opportunities to find out what kind of a psychiatrist you are and who you want to be, open up like a waterfall here at Downstate. The faculty and supporting staff are always available and there is no shortage of people to turn to for advice and guidance on the path to independence.
Working Towards a PhD
Hello! My name is Mohamed ElSayed. I am a PGY-4 resident in psychiatry enrolled in the special PhD track. The track is designed to allow people with academic interests, like myself, to pursue their interests to work in research and fulfill the requirements for a PhD degree during residency. I am currently enrolled in biomedical engineering track in PhD, and electroencephalography (EEG) is my main area of focus. Before I talk about how this works in third year, let me highlight how the PhD track was personalized for my interests during my residency.
I was interested in getting a PhD degree on my first day I started residency at Downstate. On the first few months in residency, I joined Henri Begleiter Neurodynamics lab (HBNL). Our lab is studying genetics and neurophysiologic phenotypes in alcoholics and family members of alcoholics. I attend weekly lab meetings where everyone brainstorms to come up with new ideas for research. I am also working on a project aiming at identifying the clinical and epidemiological differences in individuals who have different P3 amplitudes in EEG. Also, because of my interests in addiction, I have a great mentorship to guide me through my residency. I have worked on a quality improvement project to prescribe Naltrexone for opioid using patients who present to our CPEP. I also participated in updating the guidelines for use of psychosocial interventions for people with opioid use disorder.
Now, my week in third year goes as follows: On Mondays, I start my day at 8 am in the Brooklyn VA hospital where I see my patients at the PTSD clinic. At noon, I join my fellow residents in our weekly journal club. Last week we discussed an interesting article about transcranial magnetic stimulation (TMS). After I finish my clinic, I work on my directed reading course on signals and systems.
Tuesday, I start my day in the outpatient clinic at Kings County Hospital. At 11:30, I attend my weekly lab meetings. In the afternoon, I meet with my supervisors for psychodynamic, interpersonal and cognitive behavioral therapies. Next week, I am starting to teach a new course about psychopharmacology to our psychology interns. I continue seeing my patients till 5 pm. This week, I am on call from 5 to 10 pm.
Wednesday starts with my clinic. In the morning, I lead a weekly group therapy for feeling management. At 12 pm, I attend the weekly seminar for PhD. Last week we had an interesting speaker from Nathan S. Kline institute for psychiatry research who discussed the updates for research in neurophysiology. At 1 pm, we have our weekly psychiatry grand rounds. I then have my directed course in C programming. I continue seeing patients afterwards. At 5 pm, I have my evening clinic, where I see 1 patient for psychodynamic therapy.
Thursday is our didactics day, in addition to the residents’ meeting. We meet with our program director and our associate program director to discuss various issues related to our program. We also have all-residents’ meeting once a month to catch up with other PGY classes in residency. I also meet with my mentor from HBNL to discuss my progress in my project.
Friday morning starts in the clinic. In the afternoon, I head to the mosque to pray Jomaa. I also give a lecture to 3rd year medical students during their psychiatry rotation about neurobiology and genetics of mental illness. I then meet with my clinic team and my supervisor to discuss medication management for my cases.
Then there’s the weekends when I have fun spending time with family and friends in the exciting city of New York! It might sound busy, yet working in research and having courses together with residency is actually a lot of fun!
PGY-4: Preparing for Life Beyond Residency
Moving from PGY-3 to PGY-4, our residency program really prepares you for what will be our life beyond residency-be it fellowship or getting a job. Our fourth year is divided into two halves. One half consists of 2 days of electives a week, one day of didactics on Thursdays, and 2 days in our outpatient clinic, caring for patients we kept from our 3rd year caseload. This is a unique opportunity to follow the same patients for 2 years, delve into psychotherapy with some, and experience their journey to recovery with others. It is during these 6 months that we also do intakes with our supervising attending at Kings County, allowing us to hone our interview skills, do CSV evaluations, and learn what it is like to work as an attending in the outpatient setting.
I am currently enjoying my elective half of the year, and I spent 3 months with 2 full days on Forensic Psychiatry elective, my particular area of interest. I was matched with a supervisor who does both civil and criminal evaluations as part of his private forensic practice, and worked with him closely. I conducted criminal evaluations, did retention cases, and did civil evaluations as well. The breadth of experience I amassed in 3 months was astounding, and I felt very confident that I would be able to perform well in a forensic psychiatry fellowship.
I also am doing my second elective in addiction psychiatry, at the VA hospital in Brooklyn. The chance to work with Veterans with addictions has opened my eyes to the plight these patients endure while struggling with both their addictions and the fact that they have survived and fought through wars. It is very enlightening to see them through detoxification and inpatient rehabilitation, as well as to work with them in outpatient specialized programs, both in therapy, groups, and prescribing medications such as Suboxone.
My final elective will be in research, a particular passion of mine, and I am excited to get a chance to work with my research mentor closely. We get a chance to pursue our interests in fourth year electives, both honing the skills we will need in fellowship and beyond, and working on several projects such as research papers.
The two days we have in clinic are just like 3rd year, but with more independence. Although there are supervisors on site at all time, it is very rewarding to work with patients we have known for a while at this point, and see their progress through therapy and treatment. Supervision and intakes are once a week, and that is where we complete an intake, and go over our cases. We also attend team meetings weekly, where we get to see what being part of a complete treatment team is like, and collaborate with our social workers, case managers and nurses in our patients' care.
The second half of fourth year is where we get to do our leadership rotation, and get the true experience of being a senior resident on one of the units we have previously worked on as juniors. We get to put in our first, second and third choices for leadership rotations, and our program directors try to match us up with our interests-be it inpatient, outpatient or consult liaison psychiatry. This allows us to supervise our junior residents, mentor them, and to get a taste of what being an attending on a rotation is like.
Didactics in 4th year are focused on family therapy, sex therapy, dynamic theory, neuropsychiatry and neuroimaging, and a great class in medication management of challenging patients. We share cases that have presenting some difficulties in psychopharmacology, and discuss them in depth with one of our expert psychopharmacologists on staff. The advanced psychopharmacology class is wonderful and very informative.
I also continue to see my two long term psychodynamic psychotherapy patients in evening clinic weekly. This endeavor on the part of our program really fits into the concept of well rounded training, and continuity of care, with all of the advantages to our development that brings.
Fourth year of residency is a busy and stimulating year at Downstate, and one that is tailored to allow residents to pursue their individual and unique goals, as well as hone their skills in leadership. We get the chance to see what being a supervising resident is in practice, while we interview for fellowships, and jobs. The faculty and staff support us in all our choices, and are always ready to give guidance and advice in making life and career decisions.