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Week in the Life - PGY4

by Alex Lehecka

After having built a strong base in understanding of psychiatry from the last three years, fourth year provides the opportunity to dive deeper into your specific interests. There is huge flexibility to create a schedule that suites your desires and areas of interest; whether that be outpatient psychiatry, therapy, inpatient psychiatry, etc. Each half day provides a different venue, a fresh set of faces, and a different challenge. The schedule is dynamic enough, it is important to check at the beginning of the week to ensure you know where you are supposed to be each half day.

Weekdays start with my alarm going off at 6:30am. I attempt 5-10 minutes of mindfulness before I roll out of bed to a cup of coffee. I then take a short run along the river with my Golden Retriever before getting back to prepare for the day. I typically leave my house around 7:45am for an 8am start.

One of the perks of Spokane is that most every rotation is within 15 minutes of almost any location, most of the time less than 10 minutes.


AM: Gonzaga Psychotherapy Clinic: seeing Gonzaga students for therapy, utilizing primarily CBT, ACT, and mindfulness. This is a fun population to work with as they are highly motivated to utilize what they are taught and typically demonstrate rapid improvement. I also have the opportunity to do personal psychotherapy Monday mornings (ISTDP), which I have found has been extremely beneficial for every aspect of my life. We are fortunate enough to have the opportunity to do our own psychotherapy with a psychologist who trained with Habib Davanloo, the founder of ISTDP!

Afternoon: Head to the VA to do therapy centered on addiction. We work in concert with two PhD psychologists, utilizing CBT for substance use disorders.

Evening: Out early enough to paddle board/float the river witha couple colleagues, and of course, my puppy. We park our cars at the take out and run the trails back to my house to put in.


AM: Work ED psychiatry with a hospitalist here at Sacred Heart. This has been extremely helpful in learning the pace of clinical care as an attending, discovering what is and is not pertinent, in order to be more efficient. These mornings make me feel like the training wheels are starting to come off. This particular morning was really busy, as I saw four new patients.

PM: Meet, virtually, with attending physician and two different care coordinators (therapists). One is located in Colville and the other here in Spokane. We spend time going over six patient cases and providing recommendations to the therapists and PCP for medication management or other interventions. We have the ability to recommend in-person psychiatric visits if the patient would benefit from a higher level of care.

Evening: Bike 22 miles, from my house out Fish Lake Trail. Trying to maintain appropriate training schedule for an Ironman prior to graduation. Take the puppy for a run after so she can also displace some energy.


AM: Outpatient continuity clinic at Spokane Teaching Health Clinic. See two patients virtually and two in person.

PM: Work directly with Designated Crisis Responders. Drove to the person’s house who has not been compliant with their LRA (Less Restrictive Alternative, court-ordered treatment outside the confines of an inpatient psychiatric unit). Coordinated with police and ambulance. In the end, this person was detained for grave disability and transported to the hospital for further treatment. Amazing to see how mental health works in concert with police (specific behavioral health unit).

Evening: Soccer night. Head to public field to meet some friends for a small sided game.


AM: Head to Sacred Heart to help the team with Consult/ Liaison Psychiatry. Work directly with PGY2, PGY1, and a medical student assisting as much as possible. Enjoy having the opportunity to teach and learn from my colleagues. I am always amazed how much I glean from watching different colleagues’ styles.

PM: Protected didactic time all afternoon. First hour is T-group, where all PGY 3’s and PGY 4’s have a safe place to talk about anything and everything. This has been one of my most useful hours every week during residency. I feel so much closer to my colleagues from what we share and learn about each other. Three other lectures are included this day, all from faculty.

Evening: Tonight is my tennis night. I hit for an hour and a half with a retired IM doctor at a local park


AM: Yale wellness elective. Spend the morning listening to lectures from Yale’s free course, “The Science of Well-being.” Historically, this has been Yale’s most popular course. They provided it free online at the start of the pandemic. I have found many useful things from this course I have applied in my own life. It has also been helpful for a handful of patients.

PM: Direct patient care at STHC. This half-day I have 2 follow-ups and an intake. This intake is quite complex (late onset schizophrenia) – it made me feel fortunate to have two attendings with whom I am able to step out and have a stimulating conversation, working through differential and treatment options.

Evening: Took the night off from exercise, caught up on the Late Show and Last Week Tonight while enjoying a couple great brews from No-LI, one of our local breweries.


Sleep in, have a nice brunch. Park my car down the river six miles from the house. Take the long way running home along the river. Inflate my white-water raft, kayak, and a couple paddleboards for a long group float. We have some class 3 rapids a few miles out of town, we are not going through today though. Group of friends (mostly from our program) arrive at my place at 1pm for a long afternoon float down the river. Stop multiple times along the way to swim and chat. Spend the evening relaxing from a long day in the sun.


Enjoy a mostly lazy day watching sports and catching up on chores around the house. Spend a couple hours in the afternoon at a local crag doing some top rope climbing. Buy my season pass, for the upcoming ski season as I start my snow dance.