Adult psychiatrists accepting kids.

[softballtennis]

I know some general psychiatrists will not accept anyone under 18 but some generals will. I think a 14-17 year old teenager should be able to see a gen psychiatrist. There is not really that much diffrence in maturity in a 17 year and a 18 year old. The child and adolescent psychiatrists should only treat up through 0-14. But still I do not get why we need child and adolescent psychiatrists it seems like a pointless fellowship in residency plenty of psychiatrists have had interactions with kids.

---

Members don't see this ad.

 

[shan564]

It's not about maturity, it's about the types of illnesses that commonly manifest in patients of various ages. Same as the reason why pediatricians exist. It starts to get hazy when you get to the 14-17 range, but in the end, a doctor shouldn't treat a patient who he/she does not feel qualified to treat.

 

[whopper]

Some meds such as antidepressants don't show the same results in kids vs adults. Whenever I had a child patient in outpatient practice, even though I limited it to age 15+, I still was in a position where I sometimes couldn't tell even after a few meetings if their behavior was due to Axis I vs II.

Staying out late at night, talking back to parents, starting to do bad in school could be first break bipolar disorder. It could also be over-zealous parents, simply going through puberty, breaking up with their first girl or boyfriend...it gets damned hard, and medicating kids if they're not mentally ill IMHO should be considered heresy. Unfortunately, some doctors are willing to medicate kids as if it's giving candy to a baby.

Some of the patients I only started becoming confident what their diagnosis was after a few months of seeing them.

 

[NJWxMan]

The approach and theory behind child psychiatry is vastly different than adult psychiatry. In addition, one learns how to work for the child, but with the family as well. Medications also work much differently on kids.

I know some general psychiatrists will not accept anyone under 18 but some generals will. I think a 14-17 year old teenager should be able to see a gen psychiatrist. There is not really that much diffrence in maturity in a 17 year and a 18 year old. The child and adolescent psychiatrists should only treat up through 0-14. But still I do not get why we need child and adolescent psychiatrists it seems like a pointless fellowship in residency plenty of psychiatrists have had interactions with kids.

 

[Leo Aquarius]

...Staying out late at night, talking back to parents, starting to do bad in school could be first break bipolar disorder. It could also be over-zealous parents, simply going through puberty, breaking up with their first girl or boyfriend...it gets damned hard, and medicating kids if they're not mentally ill IMHO should be considered heresy. Unfortunately, some doctors are willing to medicate kids as if it's giving candy to a baby..

This is why I'm not going into child and adolescent psychiatry. I don't want to be wrong even once and end up medicating a single child who doesn't need it. That would be heresy indeed.

 

[notdeadyet]

The approach and theory behind child psychiatry is vastly different than adult psychiatry. In addition, one learns how to work for the child, but with the family as well. Medications also work much differently on kids.

This. Also, you use some very different psychotherapy approaches and modalities with children (and their parents).

Child is the fellowship that MOST needs it's own fellowship, in my opinion.

 

[whopper]

When I took child patients, I gave strict caveats that a child psychiatrist would likely be better, that I am only seeing the patient on the understanding that I realize there is an even worse shortage of child psychiatrists in the community and that seeing me was a better option than no psychiatrist whatsoever, and that the patient (and their parents) should strongly consider looking for a child psychiatrist in the meantime, and possibly a child psychologist.

This upset the private practice I was at. They wanted me to commercialize myself to the fullest extent. I flat-out told them no, that I was the doctor and that they didn't understand this. The practice was filled with counselors a psychologist who was the head of the practice and actually agreed wtih me but was very old and was letting his son run things, and that guy's son who I considered a bit too much into making money vs the quality of the care.

It was one of the reasons why I decided to leave private practice. That guy just kept pushing too many ventures just for the money and not thinking of the consequences.

 

[masterofmonkeys]

Ugh. General psychiatrists are trained to handle children. I would not want to work with a child with a schizophrenic father, bipolar mother, who I suspected of having a diathesis at the age of 8. But a 7 year old with anxiety or a 16 year old with early schizophrenia, why not?

Gen psych has core competency requirements in child for a reason.

 

[whopper]

General psychiatrists are trained to handle children.

Yeah just like all medical students take a core class in surgery yet you wouldn't want to be the one doing it if you're a psychiatrist. There's a reason why there's fellowships available despite the training given in residency.

Most of the general psychiatrists I've seen who think they can handle child psychiatry are exactly the shmucks out there that shouldn't be. IMHO if you see a child patient, it should only be because the case is extremely easy and/or superficial (e.g. a PES visit but no ongoing care), or because the patient is in a situation where they have no choice to see you because you're the only provider in the area.

 

[notdeadyet]

Ugh. General psychiatrists are trained to handle children....

Gen psych has core competency requirements in child for a reason.

Oi... General psych residency programs tend to have more rotations spent on neurology than on child psychiatry. Do you feel qualified to practice independently as a neurologist too?

The whole "children are not little adults" spiel holds some water. You do not approach and treat anxiety in a 7 year old the same way you do a 40 year old and you won't get proficiency in this during your CAP rotation in residency.


Sent from my iPhone using Tapatalk

 

[whopper]

I forgot to mention, like I said, only take a child case if it's going to be easy or superficial.

But if you are in private practice, the first time you see a patient, you will likely not know how bad their case is. If it's bad, and you see them, now you've already established a doctor-patient relationship, and now you're stuck treating them until you follow the termination guidelines of your state. For some people that could force your responsibility to treat at least for weeks.

And if you terminate them while they're still doing very bad, you're just going to feel like a terrible, cold-hearted, ineffective doctor, and if you don't, then you likely are one.

 

[NJWxMan]

The big kicker that you learn early in child fellowship...direct questioning in a latency child or younger almost never gets you anywhere. Interviewing children with their parents in the room gets you nowhere. You usually don't learn that in general training. Scales and screenings are almost a necessity in CAP as well. Again, tools that you need to learn how to use well.

 

[touchpause13]

I was a teenager who saw an adult psychiatrist. I couldn't get in with anyone else and the dr. I saw was a friend of my parents (i think they kinda had to beg her to take me)

It was fine, certainly better than nothing. But I would have preferred to see a child/adolescent psychiatrist if I had the option.

 

[masterofmonkeys]

Oi... General psych residency programs tend to have more rotations spent on neurology than on child psychiatry. Do you feel qualified to practice independently as a neurologist too?

The whole "children are not little adults" spiel holds some water. You do not approach and treat anxiety in a 7 year old the same way you do a 40 year old and you won't get proficiency in this during your CAP rotation in residency.


Sent from my iPhone using Tapatalk

I guess maybe I'm being a little too egoistic here. I've had probably a lot more child psych as a general resident than most get. 3 months inpt, 1 month consult, 1 day/week as a third year, and will do another 1-2 days/week as a fourth year. I have no business handling inpatient independently, nor do I have any business handling complex autism, suspected bipolar, psychotic illness, or more severe cases of OCD. But I'm fairly confident in my ability to handle childhood mood/anxiety or at least START the process of treatment; I'm also confident in my ability to know when I'm out of my depth. Much like other specialists who aren't medicine/peds based, we should have at least some degree of competence in the pediatric stuff.

 

[smalltownpsych]

I also want to state that I think that adolescents are a unique category of their own and I think many in the filed lump them together with either adults or children all too often.

 

[nancysinatra]

I agree that we should be able to handle kids. I don't see why we aren't taught it currently. The purpose of residency in my view is not to create the "best" providers but to create competent providers. We spend 4 years in training but probably have the smallest knowledge base of any medical specialty. It makes no sense to me as to why we are in trianing for so long but then are authorized to do so little. Seriously, residency to me seemed like being in that movie Groundhog's Day. It's one inpatient or consult rotation after another for an interminable period of time with absolutely no variation. Why wasn't more of that time spent on geri and child psych? If Med/Peds takes 4 years, and the Triple Board takes 5, then why on earth can't we learn less material in equal or less time?

I wouldn't compare child psychiatry to surgery or neurology. Child psychiatry is not a full fledged specialty ala general surgery. Even if it was, it would still be easier and less risky. Those fields have medical knowledge to memorize, and procedures to be practiced. They have to know radiology. And plus while there are equivalent fellowships or residencies such as child neuro and pediatric surgery, the reasoning as to why they exist is probably different. It's pretty hard in psychiatry to kill a patient due to lack of knowledge or experience.* Our malpractice rates prove that. Why else would you require more training, if not to decrease risk to patients and improve outcomes?

What I would like to know is, IS there any data showing that patient outcomes, measured in terms of cure rates, remission rates, error rates, morbidity and mortality, etc, improve if the doc has two more years of training? If not then in my view they should slash these programs and fold training into general residency.

And what is it with geri psych that it doesn't have the same taboo against non-fellowship trained people practicing it? There is a lot more risk there medically, and much more medical knowledge involved usually.

*Please don't anyone offer the "oh but there is the risk of suicide which is SOOO high and requires SOOO much experience." Bunk. Suicide risk factors can be learned by anyone with a high school diploma or equivalent in about 45 minutes. Social workers make psychiatric admission decisions in ERs all over this country for a reason - it isn't high tech.

 

[nancysinatra]

This is why I'm not going into child and adolescent psychiatry. I don't want to be wrong even once and end up medicating a single child who doesn't need it. That would be heresy indeed.

I don't think it's possible in any field of psychiatry to not be "wrong" a lot of the time, if not all the time. The DSM changes, for one thing. Plus there are no imaging or lab tests to verify a single psychiatric diagnosis. I have never seen data regarding error rates in our field, but I imagine they are quite high for everyone.

Here's a question - if the age threshold for ADHD changes from 7 to 12, then what do you do with all the kids between 7 and 12 who were told for years that they didn't have ADHD? When those kids were told they had things like bipolar instead, what is that? Is that an error? The change was made based on statistic, not based on some new physiolgical understanding of ADHD. It's not an advance of science, but merely a reworking of numbers, so you can't really justify the errors in the past to "well we didn't have the same medical knowledge then." So how do you account for those "mistakes?"

And even pediatricians must be "wrong" from time to time. Why would it be heresy to give a kid the wrong medication? It seems to me it is just a fact of life.

 

[nancysinatra]

I also want to state that I think that adolescents are a unique category of their own and I think many in the filed lump them together with either adults or children all too often.

Sure but then why don't we have a month long rotation in adolescent psychiatry?

 

[smalltownpsych]

The decisions that we make when treating children can have a profound impact on their lives. Long-term outcomes of childhood interventions are difficult to measure, but if you don't think what we do or don't do with kids can have a major impact on their lives then you haven't worked with enough kids, IMO. The whole field of psychology/psychiatry is starved for evidence, and not for lack of effort. We are just looking at a much more complex organ than a gall bladder!

 

[nancysinatra]

The big kicker that you learn early in child fellowship...direct questioning in a latency child or younger almost never gets you anywhere. Interviewing children with their parents in the room gets you nowhere. You usually don't learn that in general training. Scales and screenings are almost a necessity in CAP as well. Again, tools that you need to learn how to use well.

Do you know of a reason why this stuff isn't taught in general residency? Surely we could have sacrificed the ACGME's mandatory Sleep Lecture, and the endless pretentious lectures about "Boundary Violations" and "Professionalism and Social Media" and learned the stuff you're talking about.

 

[smalltownpsych]

Sure but then why don't we have a month long rotation in adolescent psychiatry?

I would say that we should. My treatment plans, approach, and diagnostic formulations vary dramatically for children, adolescents, and adults. Oh and don't forget geriatric populations. Don't even get me started on how little physicians understand the aging brain and the treatment errors that they make because of this.

 

[nancysinatra]

The decisions that we make when treating children can have a profound impact on their lives. Long-term outcomes of childhood interventions are difficult to measure, but if you don't think what we do or don't do with kids can have a major impact on their lives then you haven't worked with enough kids, IMO. The whole field of psychology/psychiatry is starved for evidence, and not for lack of effort. We are just looking at a much more complex organ than a gall bladder!

You think the gall bladder is not complex?

if you don't think what we do or don't do with kids can have a major impact on their lives then you haven't worked with enough kids, IMO.

But like I said, the Triple Board takes 3 years. Med/Peds takes 4 years. Do these peole NOT have a "major impact" on the lives of kids they treat?

Actually the known science pertaining to the heart, lungs, pancrease, bones, immune system and other organs is probably way more sophisticated than anything we "learn" about the brain in psych residency, so if you use organ complexity to justify the length of training, then all of psychiatry, child included, should take less time than these other specialties.

Personally, I learned almost nothing about the human brain in my general psychiatry residency. What about others? Did you learn a lot of complex stuff regarding the brain?

 

[nancysinatra]

Don't even get me started on how little physicians understand the aging brain and the treatment errors that they make because of this.

What are some of the errors you see?

 

[nancysinatra]

xxx

 

[smalltownpsych]

What are some of the errors you see?

Prescribing opiates and valium to a senior with COPD which led to substance induced delirium and subsequent )2 deficiency which led to significant decrease in cortical functioning. Patient went from being independent and able to care for self to needing assisted living. I have seen milder opiate induced delirium in two of my elderly relatives that led to numerous falls. Fortunately, neither was injured seriously and when taken off the opiates they were both able to function normally. These folks were not opiate seeking, they just made the mistake many of the older generation do of "trust your doctor".

 

[smalltownpsych]

You think the gall bladder is not complex?



But like I said, the Triple Board takes 3 years. Med/Peds takes 4 years. Do these peole NOT have a "major impact" on the lives of kids they treat?

Actually the known science pertaining to the heart, lungs, pancrease, bones, immune system and other organs is probably way more sophisticated than anything we "learn" about the brain in psych residency, so if you use organ complexity to justify the length of training, then all of psychiatry, child included, should take less time than these other specialties.

Personally, I learned almost nothing about the human brain in my general psychiatry residency. What about others? Did you learn a lot of complex stuff regarding the brain?

I wasn't referring to organ complexity. Obviously, the brain is not that complex at a purely functional level. I am referring to the complexities of how the brain relates to human behavior/cognition/emotions. Do we really understand the biological mechanisms of any of the mental disorders? Or the causes? The DSM intentionally leaves out etiology as an aspect of diagnostic classification. What about the fine line between the psychological and the physical?
I would say that part of the reason that you learn so little about the brain as opposed to other organs is that so little is understood about it. Take Dr. Frankenstein's word for it.

 

[michaelrack]

Do you know of a reason why this stuff isn't taught in general residency? Surely we could have sacrificed the ACGME's mandatory Sleep Lecture, and the endless pretentious lectures about "Boundary Violations" and "Professionalism and Social Media" and learned the stuff you're talking about.

Don't sacrifice Sleep

 

[billypilgrim37]

I would say in general if you don't see child psychiatry as a really complex, dynamic field , you're probably doing it very poorly. It doesn't take long to learn how to treat children, but it does take a long time to learn how to assess them, navigate their systems, and work with their families. If somebody didn't think that was a big deal that required quite a bit of extra training, I really wouldn't them treating kids!

Also, triple boarders are typically a) mutantly smart and driven, and b) competent but not good at adult psychiatry.

 

[smalltownpsych]

I would say in general if you don't see child psychiatry as a really complex, dynamic field , you're probably doing it very poorly. It doesn't take long to learn how to treat children, but it does take a long time to learn how to assess them, navigate their systems, and work with their families. If somebody didn't think that was a big deal that required quite a bit of extra training, I really wouldn't them treating kids!

Also, triple boarders are typically a) mutantly smart and driven, and b) competent but not good at adult psychiatry.

I never heard of triple boarders. Some of the kids I work with are long boarders, they don't meet criteria a), but they might have some potential to meet b). After all, many of them do like to experiment with psychotropics, although they tend to prefer the "natural" drugs verses the prescription type.

 

[nancysinatra]

I wasn't referring to organ complexity. Obviously, the brain is not that complex at a purely functional level. I am referring to the complexities of how the brain relates to human behavior/cognition/emotions. Do we really understand the biological mechanisms of any of the mental disorders? Or the causes? The DSM intentionally leaves out etiology as an aspect of diagnostic classification. What about the fine line between the psychological and the physical?
I would say that part of the reason that you learn so little about the brain as opposed to other organs is that so little is understood about it. Take Dr. Frankenstein's word for it.

Yeah so then my question is, what the heck are the four years of psychiatry residency actually being spent doing, since the amount of knowledge that is known in the world about the brain and behavior is rather low?

 

[nancysinatra]

I would say in general if you don't see child psychiatry as a really complex, dynamic field , you're probably doing it very poorly. It doesn't take long to learn how to treat children, but it does take a long time to learn how to assess them, navigate their systems, and work with their families. If somebody didn't think that was a big deal that required quite a bit of extra training, I really wouldn't them treating kids!

Also, triple boarders are typically a) mutantly smart and driven, and b) competent but not good at adult psychiatry.

Right but my point was - residency doesn't need to make people "great" at their field. I't only needs to produce clinicians who are competent. (Or if it does produce exceptionally good clinicians, why doesn't the pay rise dramatically with each year that residents get closer to that "greatness?") I have no problem with the existence of fellowships where people can develop greater expertise in child psychiatry; what I have a problem with is the failure to teach the subject to such a minimal level of competency during the four years of glorified social work known as "general psychiatry residency."

General internists practice cardiology, GI, immunology and everything else without having done fellowships. I suppose they each have different comfort levels for deciding when to call consults. But it's not like it's "illegal" for a general internist to treat patients with heart disease. Whereas it's very taboo for a general psychiatrist to treat kids, to the point where people start talking about malpractice. Yeah you gotta know when to consult but to act like child psychiatry is so difficult that it can't be touched by general psychiatrists is just plain weird.

 

[nancysinatra]

I never heard of triple boarders. Some of the kids I work with are long boarders, they don't meet criteria a), but they might have some potential to meet b). After all, many of them do like to experiment with psychotropics, although they tend to prefer the "natural" drugs verses the prescription type.

Triple Board is a residency that is 5 years long and leads to board eligibility in pediatrics, child and adult psychiatry.

 

[nancysinatra]

Don't sacrifice Sleep

Sorry to get off track, but do you know the ACGME Mandatory Sleep Lecture I'm talking about? Literally it's a lecture informing residents about what sleep is and why it is important for humans to sleep sometimes. Seriously someone from pulmonology stands at the front of the room and tells everyone about how humans need to sleep, every single day. They bring up really illustrative examples such as describing the effects of sleep deprivation on driving skills. Turns out you can actually fall asleep at the wheel if you're tired enough. I mean, who knew?

Here's an example:

 

[birchswing]

I've said this in another thread, but at 14 I saw a general psychiatrist. At the time, I can remember my parents calling our HMO and telling them how bad off I was and that I needed to see someone. We had some type of insurance where they picked your doctor. It turned out the one they picked happened to be the father of a guy I knew in school, and whose house I would go to occasionally with groups of friends. It was all very awkward. I only saw him once, and I know people always say this, but I swear it was like a 5-10 minute appointment. He diagnosed me with panic disorder and put me on 2 mg Ativan daily. I never saw him again (except at his house sometimes), as his wife was a nurse who did all follow-up appointments and just kept re-prescribing the Ativan. Eventually they put me on 10 mg Paxil (why such a small dose, I don't know). I had no idea Ativan was addictive. In fact, I was terrified of going on medication. When I asked him questions about the medication, he said, "Do you tell the pilot how to fly the plane?" The way he described the drug was by saying that my head was like a barn and that the horses had run wild. This medication would put the horses back in the barn. He was an FMG, and in my experience, these types of folkisms are common with FMG psychiatrists I have seen. I had no idea there was such a thing as a child psychiatrist. When I see whopper write that it would take him months to calculate a diagnosis in children, it makes me angry. It makes me angry because it confirms exactly how bad my treatment was by comparison. I'm also going through a benzo taper right now, so my feelings about all of this are more intense than usual. Good psychiatrists need to help put bad psychiatrists out of business somehow. When I think of how much was known about benzodiazepines even back in the 1970s, the idea of giving them to a 14-year-old as a first-line treatment in the late 1990s indefinitely makes me furious. There has to be some right to your own brain's health. I am not against psychiatric treatment. I'm against people who screw up because they don't seem to care enough to worry that they might screw up so they stay mired in misinformation.

 

[TexasPhysician]

As a general resident I wondered if I really needed this C&A fellowship to treat them effectively. In fellowship, I learned how badly the fellowship is needed to be effective.

 

[hamstergang]

Personally, I learned almost nothing about the human brain in my general psychiatry residency. What about others? Did you learn a lot of complex stuff regarding the brain?

the four years of glorified social work known as "general psychiatry residency."

We get it, you had really bad training in residency for whatever reason. But don't be projecting all of that onto the rest of us who are actually learning the medical specialty of psychiatry. Your posts downplay the amount of thinking and knowledge that goes into an actually good psychiatric practice, and so of course you see little issue with treating patients of all ages -- you just seem to ignore all the complexity and so any one patient seems just as easy as the next to you.

 

[Armadillos]

nancysinatra

you don't seem to think very highly of psych from an intellectual challenge standpoint (either that or you feel your much better than most psychiatrists at psychiatry so its uniquely easy for you). And it seems that this doesn't sit well with you because you seem to always complain about it. So what are you doing to make psych personally for interesting or challenging to you? Seems like if someone were in your place they would be doing something to quickly elevate themselves in the field like gunning to become chairman of a program or building up a hugely successful "VIP" type practice in a big city by word of mouth, becoming a renowned expert forensic evaluator, joining some cutting edge research group, taking some floundering community mental health agency and turning it around, etc, etc.

If you feel like your skills are just that of a "glorified social worker", then why not go out and make yourself more than that?

 

[billypilgrim37]

Right but my point was - residency doesn't need to make people "great" at their field. I't only needs to produce clinicians who are competent. (Or if it does produce exceptionally good clinicians, why doesn't the pay rise dramatically with each year that residents get closer to that "greatness?") I have no problem with the existence of fellowships where people can develop greater expertise in child psychiatry; what I have a problem with is the failure to teach the subject to such a minimal level of competency during the four years of glorified social work known as "general psychiatry residency."

Most specialties do not treat both children and adults. Family medicine does, but they do everything and are trained very specifically to get a sense of when they need help and when they don't. Most family docs also don't treat childhood psych issues, but treat adult issues all the time. Most pediatricians, if they can get away with it, will defer treating childhood psych issues (though many find themselves in the position of having to). An adult cardiologist is not going to see a child (though pediatric cardiologists may see adults). That's true for most specialties. In areas where there are pediatric subspecialists, most adult subspecialists don't touch many children. In a community with a few trained pediatric dermatologists, very few kids will see adult dermatologists, but somewhere where the pediatric specialists don't exist will probably see the adult doc (similar to psychiatry).

So the developmental difference between c&a and adult is a pretty big deal across medicine and surgery, not just in psychiatry. And when pediatric providers exist, the chance of adult providers providing care to children is much less common.

 

[nancysinatra]

nancysinatra

you don't seem to think very highly of psych from an intellectual challenge standpoint (either that or you feel your much better than most psychiatrists at psychiatry so its uniquely easy for you). And it seems that this doesn't sit well with you because you seem to always complain about it. So what are you doing to make psych personally for interesting or challenging to you? Seems like if someone were in your place they would be doing something to quickly elevate themselves in the field like gunning to become chairman of a program or building up a hugely successful "VIP" type practice in a big city by word of mouth, becoming a renowned expert forensic evaluator, joining some cutting edge research group, taking some floundering community mental health agency and turning it around, etc, etc.

If you feel like your skills are just that of a "glorified social worker", then why not go out and make yourself more than that?

How do you know I am not doing one of those things?

I didn' say my SKILLS were that of a "glorified social worker." I was referring to my experience in residency as seeming like glorified social work. Maybe other programs are more interesting. (I did have some good rotations, by the way. But the aggregate was a lot of repetition.)

Anyway here is take a typical day on one of my inpatient rotations:

Morning - in rounds, typically dominated by various non-medical members of the "multidisciplinary team"
After rounds, doing such exciting tasks as "getting collateral" or "holding a family meeting"
At some point during the day I often had to attend some kind of lecture. 99.999999% of the time that lecture would be on one of the following topics: Boundary Violations, Professionalism, Social Media and its Misuses, or my personal favorite waste of time, Work Life Balance
I had to write my notes, the purpose of which is a) to prevent lawsuits and b) to fill out as many redundant little check boxes and system alerts as humanly possible.
I always had some number of meaningless forms to fill out for the program office. Oh, and verifications that I had competed each hospital's "HIPAA privacy training module"
At other times we'd have some "conference" where there would be some 2 minute discussion about a case, and then the rest of the time people would go around the room asking questions, usually of a logistical nature.

 

[nancysinatra]

We get it, you had really bad training in residency for whatever reason. But don't be projecting all of that onto the rest of us who are actually learning the medical specialty of psychiatry. Your posts downplay the amount of thinking and knowledge that goes into an actually good psychiatric practice, and so of course you see little issue with treating patients of all ages -- you just seem to ignore all the complexity and so any one patient seems just as easy as the next to you.

I don't see "little issue" in treating patients of all ages. I do think people should know when to consult the right sub specialist. But you can make that argument about geri psych too, and yet no one does. Same with every other subspecialty.

My point is only that I don't see why we can't utilize our 4 years a little more efficiently and thus be more competent to treat kids at a basic level so that we can do some initial workups and treat straightforward things, and refer out more complicated cases.

 

[nancysinatra]

Most specialties do not treat both children and adults. Family medicine does, but they do everything and are trained very specifically to get a sense of when they need help and when they don't. Most family docs also don't treat childhood psych issues, but treat adult issues all the time. Most pediatricians, if they can get away with it, will defer treating childhood psych issues (though many find themselves in the position of having to). An adult cardiologist is not going to see a child (though pediatric cardiologists may see adults). That's true for most specialties. In areas where there are pediatric subspecialists, most adult subspecialists don't touch many children. In a community with a few trained pediatric dermatologists, very few kids will see adult dermatologists, but somewhere where the pediatric specialists don't exist will probably see the adult doc (similar to psychiatry).

So the developmental difference between c&a and adult is a pretty big deal across medicine and surgery, not just in psychiatry. And when pediatric providers exist, the chance of adult providers providing care to children is much less common.

Yeah but lots of parts of the country don't have every subspecialty under the sun. I doubt there is a pediatric ophthalmologist for 200 miles from where I'm at. I think we may just have an optometrist actually.

I just looked it up and it looks like ophtho and derm have 1 to 2 year pediatric fellowships. So 1 year is an option. Why don't we have that option? Not everyone wants to be the cream of the crop. It's well known that adult psych can be completed in 3 years because of the existence of the fast track. If there was a 1 year child fellowship, then 4 years would be enough to do everything. EM has variable length residencies - why can't psych?

 

[nancysinatra]

We get it, you had really bad training in residency for whatever reason. But don't be projecting all of that onto the rest of us who are actually learning the medical specialty of psychiatry. Your posts downplay the amount of thinking and knowledge that goes into an actually good psychiatric practice, and so of course you see little issue with treating patients of all ages -- you just seem to ignore all the complexity and so any one patient seems just as easy as the next to you.

Ok let me just respond a bit more to this. I do complain on this forum a lot. It is the only place I can really do that. I'm not going to give lots of specifics about my residency experience because I don't want to identify the place. Hence I make snide but vague comments as a way of venting my misery from that period which I am still recovering from. Anyway the place had financial issues. It affected the training. The attitudes in that part of the country were depressing to me. But even at another program, I probably would have gotten jaded, unless I managed to get into some really cool research niche, like zoonotic diseases and their psychiatric impacts. (For awhile I wanted to study the psychiatric affects of rabies. That sounds cool! But where could I do that?) I went into psychiatry because I was interested in some of the psychoanalytical ideas, and in neuroscience, and in personality disorders and eating disorders. I saw no eating disorders in residency, and while I did get excellent exposure to personality disorders, by and large we were dealing with mood and psychotic disorders and substance abuse. I will be honest - I have no interest in most of that kind of bread and butter psychiatry. I mainly picked this specialty because the psych residents and attendings at my med school were nice and I liked the rotations. The other specialties were full of gunners which turned me off. I can do the job and I can empathize, and I care about the patients, but the bread and butter conditions don't interest me and never have. So I am bored, although my current position is at least pleasant. I was even more bored in residency because I had no say in things. At least now I can plot my next few moves and work on doing something interesting.

 

[splik]

you should do forensics. i do agree that psychiatry could be streamlined to a 3 year residency but only if you took out psychotherapy training. good psychotherapy training (specifically psychodynamic psychotherapy) does require that longitudinal experience of seeing patients over 2 (and ideally 3) years. again, i think the longitudinal aspect is what lengths psychiatric training. also other specialties work twice as many hours (1.5x as much at least) than we do in psychiatry so if you did an hourly comparison, other specialties like IM might actually come out ahead it terms of training time. there are of course dual med/psych patients where they streamline psych into 2.5 years by taking out the psychotherapy training.

i do think they could make better use of the time. that said, i feel like 4 years is too short to learn all the things i want, i can't possibly do all the rotations i want or get all the psychotherapy training i want.

i recently wrote a draft of a paper 'science and pseudoscience in psychiatric training' arguing that there was too much pseudoscience and not enough science in psychiatric residency training. unfortunately i was told it needed to be toned down to get published and it's not very interesting now!

 

[slappy]

you should do forensics. i do agree that psychiatry could be streamlined to a 3 year residency but only if you took out psychotherapy training. good psychotherapy training (specifically psychodynamic psychotherapy) does require that longitudinal experience of seeing patients over 2 (and ideally 3) years. again, i think the longitudinal aspect is what lengths psychiatric training.

A way around this could be to do the outpatient year in PGY2 and follow the psychodynamic patients through inpatient PGY3 year. Not my original idea as I remember a program on my interview trail doing exactly that (to provide 3 years of longitudinal experience instead of 2 at other programs).

i recently wrote a draft of a paper 'science and pseudoscience in psychiatric training' arguing that there was too much pseudoscience and not enough science in psychiatric residency training. unfortunately i was told it needed to be toned down to get published and it's not very interesting now!

Find a different publisher!

 

[michaelrack]

Sorry to get off track, but do you know the ACGME Mandatory Sleep Lecture I'm talking about? Literally it's a lecture informing residents about what sleep is and why it is important for humans to sleep sometimes. Seriously someone from pulmonology stands at the front of the room and tells everyone about how humans need to sleep, every single day. They bring up really illustrative examples such as describing the effects of sleep deprivation on driving skills. Turns out you can actually fall asleep at the wheel if you're tired enough.

I didn't realize it was a resident safety lecture. Still, I did quickly look through the slides and there does appear to be some useful info regarding circadian rhythms and the half-life of caffeine, as well as sleep fragmentation- but I guess that could be condensed down to 20 minutes. So I would estimate that only 2/3 of that lecture is a waste

 

[Shikima]

Sorry to get off track, but do you know the ACGME Mandatory Sleep Lecture I'm talking about? Literally it's a lecture informing residents about what sleep is and why it is important for humans to sleep sometimes. Seriously someone from pulmonology stands at the front of the room and tells everyone about how humans need to sleep, every single day. They bring up really illustrative examples such as describing the effects of sleep deprivation on driving skills. Turns out you can actually fall asleep at the wheel if you're tired enough. I mean, who knew?

I feel your pain on the 'sleep lecture/deprivation' requirement that the ACGME puts out. I often felt the same way about it and it was grossly glossed over and pushed into the closet with the rest of the ACGME skeletons.

 

[smalltownpsych]

How do you know I am not doing one of those things?

I didn' say my SKILLS were that of a "glorified social worker." I was referring to my experience in residency as seeming like glorified social work. Maybe other programs are more interesting. (I did have some good rotations, by the way. But the aggregate was a lot of repetition.)

Anyway here is take a typical day on one of my inpatient rotations:

Morning - in rounds, typically dominated by various non-medical members of the "multidisciplinary team"
After rounds, doing such exciting tasks as "getting collateral" or "holding a family meeting"
At some point during the day I often had to attend some kind of lecture. 99.999999% of the time that lecture would be on one of the following topics: Boundary Violations, Professionalism, Social Media and its Misuses, or my personal favorite waste of time, Work Life Balance
I had to write my notes, the purpose of which is a) to prevent lawsuits and b) to fill out as many redundant little check boxes and system alerts as humanly possible.
I always had some number of meaningless forms to fill out for the program office. Oh, and verifications that I had competed each hospital's "HIPAA privacy training module"
At other times we'd have some "conference" where there would be some 2 minute discussion about a case, and then the rest of the time people would go around the room asking questions, usually of a logistical nature.

No wonder you express so much frustration! It doesn't sound like you get much of a chance to provide treatment. To me the excitement really comes from grappling with the deeper issues that our patients have. I would suggest carving out an hour or two a week to provide deeper psychotherapy to a Borderline patient. Not an older burnt-out type, but the younger acting out type. Get into that patient's world from a psycho-dynamic standpoint and things might get a bit more interesting. When I was working inpatient, I loved to take a patient who was using projective identification to put all of their frustrations into the staff and begin helping them express their anger and hostility more directly. Usually I wouldn't get much credit, but the patient would stop hurting themselves and stop being put into seclusion and restraints. The rest of the staff could not do that. The best they usually had was punishment which obviously led to the predictable short-term decrease of the behavior, then relapse and increased frustration of staff directed toward patient. The truth is that at the locations where I worked, the predominantly FMG psychiatrists were as clueless about these dynamics as the rest of the staff.

 

[hamstergang]

Anyway here is take a typical day on one of my inpatient rotations:

Morning - in rounds, typically dominated by various non-medical members of the "multidisciplinary team"
After rounds, doing such exciting tasks as "getting collateral" or "holding a family meeting"
At some point during the day I often had to attend some kind of lecture. 99.999999% of the time that lecture would be on one of the following topics: Boundary Violations, Professionalism, Social Media and its Misuses, or my personal favorite waste of time, Work Life Balance
I had to write my notes, the purpose of which is a) to prevent lawsuits and b) to fill out as many redundant little check boxes and system alerts as humanly possible.
I always had some number of meaningless forms to fill out for the program office. Oh, and verifications that I had competed each hospital's "HIPAA privacy training module"
At other times we'd have some "conference" where there would be some 2 minute discussion about a case, and then the rest of the time people would go around the room asking questions, usually of a logistical nature.

I find it interesting that you don't mention interacting with or treating patients as part of your typical inpatient day. That's what your job actually was and you didn't find it worth mentioning.

As for the notes, it's not difficult to fulfill those requirements and still write a good note that explains how the patient is doing (by self report and exam), explains your plan, and provides justification for that plan. You're choosing to focus on the negatives and again ignore the work you're actually supposed to be do.

 

[Therapist4Chnge]

Also, triple boarders are typically a) mutantly smart and driven, and b) competent but not good at adult psychiatry.

I'm still trying to decide if I'd want to be mutantly smart. I mean, smart is great…but mutantly smart…great…er?

 

[OldPsychDoc]

I feel your pain on the 'sleep lecture/deprivation' requirement that the ACGME puts out. I often felt the same way about it and it was grossly glossed over and pushed into the closet with the rest of the ACGME skeletons.

And then there's those of us who get to painstakingly document that each resident has received this lecture and the patient safety lecture and the confidentiality lecture and the infection control lecture and gottentheir TB mask fit test and...