Adult psychiatrists accepting kids.

[Shikima]

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...

Totally appreciate the tediousness of such boring matters. The difficulty with sleep is that it's a needed task to complete to mentally and emotionally ready us for the day's work.

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[peppy]

I definitely think that we could use our time in residency more efficiently. I expect that within the next 10 years other fellowships besides child will allow fast tracking after 3 years of residency. That would probably allow more fellowships to fill and doing a fellowship would be more productive than doing a bunch of easy PGY4 electives as most people in my residency do.

I doubt it will ever happen but if I could, I would cut back on the amount of time spent on psychodynamic therapy in general residency and use that time to focus on things such as child psychopharmacology.

Yes the psychodynamic aspects of therapy can be interesting to talk about, but I think it is inefficient to spend so much time (at least in my residency) on something most psychiatrists won't actually spend a lot of time doing after residency. It'd be better left as a sub specialty IMO.

There are a lot of children who need psych care. There aren't THAT many people who are 1) truly good patients for long term psychodynamic therapy. 2) actually want long term therapy and 3) can afford it.

 

[MacDonaldTriad]

The big difference between allowing child to fast track and letting everyone fast track is the fact that child is 2 years. If we let everyone fast track into one year programs, almost everyone will be doing fellowships because why not? This will greatly advantage large programs with multiple fellowships and decimate small and moderate sized community programs. I would argue that residents actually do learn things in their 4th year. If what now takes 5 years will become 4 years, there has to be something taken from somewhere. Psychodynamic learning would have less longitudinal time and research would probably drop as there would be almost no elective time. I guess it is fairly obvious where I lie on this debate.

 

[smalltownpsych]

I definitely think that we could use our time in residency more efficiently. I expect that within the next 10 years other fellowships besides child will allow fast tracking after 3 years of residency. That would probably allow more fellowships to fill and doing a fellowship would be more productive than doing a bunch of easy PGY4 electives as most people in my residency do.

I doubt it will ever happen but if I could, I would cut back on the amount of time spent on psychodynamic therapy in general residency and use that time to focus on things such as child psychopharmacology.

Yes the psychodynamic aspects of therapy can be interesting to talk about, but I think it is inefficient to spend so much time (at least in my residency) on something most psychiatrists won't actually spend a lot of time doing after residency. It'd be better left as a sub specialty IMO.

There are a lot of children who need psych care. There aren't THAT many people who are 1) truly good patients for long term psychodynamic therapy. 2) actually want long term therapy and 3) can afford it.

I wonder if some of what you are experiencing as psychodynamic training is more "old school" i.e. more based on the classical Freudian stance. That would definitely make it seem tedious and less useful. I conceptualize and treat patients all the time using psychodynamic theory but I don't have the patience for a non-directive approach and I don't think it is that useful. More modern psychodynamic theory can actually be integrated with CBT or DBT techniques and strategies and can obtain quick results. Also, if you are intersted in children, then most psychodynamic approaches or theory would be a complete waste of time.

 

[birchswing]

I wonder if some of what you are experiencing as psychodynamic training is more "old school" i.e. more based on the classical Freudian stance. That would definitely make it seem tedious and less useful. I conceptualize and treat patients all the time using psychodynamic theory but I don't have the patience for a non-directive approach and I don't think it is that useful. More modern psychodynamic theory can actually be integrated with CBT or DBT techniques and strategies and can obtain quick results. Also, if you are intersted in children, then most psychodynamic approaches or theory would be a complete waste of time.

Is there a name for psychodynamic theory that isn't Freudian, ie, something I could look up on Wikipedia? I've taken intro psych classes (normal, abnormal, developmental), and they discussed Freud, Jung, Erikson, and then sort of dismissed them (well, not so much Erikson), and then went into more modern thinkers (Skinner, Ellis) but not modern psychodynamic thinkers.

 

[erg923]

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.

Sorry. But I have to ask. Whats this hostility about?

Maybe you are more mature than me, but I appreciated efforts at personal-professional development on the part of my training programs, as well discussions (although not "lectures") regarding how we navigate the most initiate of relationships in this digital age.

And I especially liked the guidance about how to balance life and work so that one minimizes risk of burnout as we continue our professional journeys. Although, I carried certain life/family values into graduate training, I appreciated that I had resources that I could tap into and emulate so that I could be a successful husband, father, and engaged professional...all at the same time.

I think the above all all important aspects of "professional training"...which is what residency is all about.

 

[smalltownpsych]

Is there a name for psychodynamic theory that isn't Freudian, ie, something I could look up on Wikipedia? I've taken intro psych classes (normal, abnormal, developmental), and they discussed Freud, Jung, Erikson, and then sort of dismissed them (well, not so much Erikson), and then went into more modern thinkers (Skinner, Ellis) but not modern psychodynamic thinkers.

Look up Self Psychology or Object Relations. Some authors are Kernberg and Kohut. Also, I forget the author off the top of my head but he writes about the Intersubjective Third. Also, look into theNeurobiology of Attachment by Lou Cozolino (a professor of mine).

 

[OldPsychDoc]

Sorry. But I have to ask. Whats this hostility about?

Maybe you are more mature than me, but I appreciated efforts at personal-professional development on the part of my training programs, as well discussions (although not "lectures") regarding how we navigate the most initiate of relationships in this digital age.

And I especially liked the guidance about how to balance life and work so that one minimizes risk of burnout as we continue our professional journeys. Although, I carried certain life/family values into graduate training, I appreciated that I had resources that I could tap into and emulate so that I could be a successful husband, father, and engaged professional...all at the same time.

I think the above all all important aspects of "professional training"...which is what residency is all about.

I think in many situations, however, what Nancy is complaining about takes on the dimension of "Mandatory Diversity Training"--where someone from HR sits you in a room and tells you what you can and should do and not do. Then your PD gets to document to the ACGME that "Yes, we have covered this" and the hospital's DIO gets off your back. It becomes an administrative mandate, not an issue of professional development, and is therefore rightly despised. And when it is billed as "Program Didactics" instead of say, teaching critical thinking, evidence based medicine, or even descriptive psychopathology--then it's quite frankly not "training" at all.

 

[billypilgrim37]

And I especially liked the guidance about how to balance life and work so that one minimizes risk of burnout as we continue our professional journeys.

It's usually far too little, far too late. The resentment that comes with someone talking to you about work-life balance when the same people talking to you are making you work a lot of inefficient hours is pretty intense. Working a 14 hour day is one thing, but when 6 hours of that 14 hour day involves things like, "trying to get the printer to work," "doing paperwork that a high school graduate could easily do," and "waiting around for other people to finish their job without any real ability to use that time in a meaningful way," then you pretty much want to tell someone who is trying to talk to you about work life balance to go **** themselves.

And there are few things as ironic as someone giving you a lecture on the importance of sleep when you're post-call.

 

[Armadillos]

yeah, I'm almost always the type to give the benefit of the doubt to those in charge at the macro level, because I figure they must know something to be in charge, but this stuff is the big exception. I think the current trend towards "over documenting" medical education at all levels is pretty damaging. As medstudents we are constantly doing random stuff just for the sake of checking off some checkboxes for the next accreditation visit. Stuff that often seems to detract from the traditional educational experience for the sake of appeasing someone's pet project. And it just seems to be spiraling and spiraling. Also it gives strong incentive to borderline dishonesty/cutting corners in order to navigate the BS extra documentation so you can actually accomplish the learning you need to. Medstudents always are having all these random requirements they need to get attendings to verify they completed and it gets to the point where often you just sit down and the attending signs a huge stack of random stuff for all the rotating students with basically no idea whats in there. Looks amazing on paper for the medschool to say look at all this awesome educational experience our students got, but its just a ruse.

I kind of wish one of the very well known medschools could just be like F-this, we know how to train physicians we are going to train our physicians how we want to because we are the best in the world and drop all this extra BS documentation of every little thing. Granted I imagine a lot of this extra bureaucracy is being driven by some of the big name medschool types, but I can always dream.

 

[nancysinatra]

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!

Splik will you keep us posted about that article? I am super interested in that topic! Wow who knew someone other than me thinks that psychiatry training has too much pseudoscience? Seriously, PM me if you have more info!

And I do agree that psychotherapy training takes longer than anything else we learn. I do see the value in long term training for that. But maybe it could modeled along the lines of psychoanalytic training, which is done part time, allowing people to work at real jobs along side.

 

[nancysinatra]

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.

Ok first of all hamster gang, you have no idea if I "do what I'm supposed to do or not," or if I'm "ignoring" my work. And the last I heard, I can do whatever I want with my life. I can even spend it complaining!

As far as notes go, in a perfect world you are right, but this is not such a world. I actually like old paper charts the best. The EMRs are all still full of snafus and poor design.

Now let me address your first point. You're right I didn't mention interacting with patients. I am not really thrilled about interacting with patients, except certain types. For example, I like asking about a history of conduct disorder because the fire setting, vandalism and truancy questions are cool. Fire starting, etc., is totally different from depression symptoms, etc. Fire starting is either yes or no and true or false, and often, there's a police record. There are no police records for insomnia, low energy, etc. And there is no "boring" case of arson, especially by youngsters.

Now insomnia, low energy, etc. is by nature extremely boring to hear about. I bet there is even literature about the countertransference of psychiatrists towards depressed patients that would show, that depressed patients invoke a feeling of dreariness and hopelessness on the part of the psychiatrist. Anyone who claims it's "interesting" to listen to people talk about their low energy, etc. is weird, and should probably not be in a patient care position. I am sure I am not alone!! And there's your bread and butter of psychiatry!

And it's not the individual patients I mind, it's doing the same thing all day and having no impact on the world, and often, no impact on the patients since our treatments are not exactly highly precise neurosurgical techniques with exactly defined effect rates, and the DSM is not exactly cutting edge science and mental health care is not exactly the priority of this nation. I say "no impact" not because I am being "negative" but because literally, I do not see a change in the world as of yet, and I do not see an overall improvement in the mental health of my patient population. Some get better, and others get worse. They cancel out. Hence: no impact. I am not being negative, just objective. This is just how I look at my job. I'm sure others have a different focus. But honestly some days I sit there and think, "I could be more effective doing crime. Robbing banks, whatever."

But to clarify, on the inpatient unit what I would do is this: I would walk around the hallway in a manner called "rounding" and I would ask people how they slept, about medication side effects, if they're hearing voices, if they feel suicidal. On my face would be an expression of curiosity and concern. I would then proceed to a computer, usually one with numerous problems, where I reproduce these interesting comments in my notes. I would also choose from among the 50 or so standard medications of essentially unknown pharmacologic mechanism that we use, some appropriate treatment. Oh, and, lo and behold, I make "empathic" statements in which I "reflect back" the emotions they are expressing. Sometimes I would make "interpretations" and sometimes I would try to "motivate." Does that clarify things?

 

[nancysinatra]

So to get back to the topic of this thread, it was about adult psychiatrists seeing kids. What I notice about this thread is that people are defending the fellowships because they find them "useful." Ok I would never challenge that, especially since I haven't done one. What I was trying to get at was, where's the data showing the outcomes improve with this model of training?

Because I'm sitting here thinking, wait, there is a huge shortage of child psychiatrists, there is a disincentive to go to fellowship which is loan interest accumulation, and right now, more and more kids are being seen by people who didn't even to go medical school! NPs, etc. So how can we possibly defend this system as being the only model we are willing to accept?

 

[nancysinatra]

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

True enough. I wish we had learned more about sleep medicine in psych residency. That sample lecture was just one I found online.

 

[nancysinatra]

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...

I feel your pain.

 

[nancysinatra]

Sorry. But I have to ask. Whats this hostility about?

Maybe you are more mature than me, but I appreciated efforts at personal-professional development on the part of my training programs, as well discussions (although not "lectures") regarding how we navigate the most initiate of relationships in this digital age.

And I especially liked the guidance about how to balance life and work so that one minimizes risk of burnout as we continue our professional journeys. Although, I carried certain life/family values into graduate training, I appreciated that I had resources that I could tap into and emulate so that I could be a successful husband, father, and engaged professional...all at the same time.

I think the above all all important aspects of "professional training"...which is what residency is all about.

Ok well, partly it's the way those things are presented. I basically see those "Stay Away From Facebook" lectures (usually it's stated in innocuous sounding terms like "everything you post should be considered public,") as trying to do 2 things: 1) justify intrusive surveillance of residents' personal lives by humorless, paranoid, Orwellian-inspired administrators that dominate certain quarters of academic medicine and who usually live for the erotic thrill of filling out forms and implementing "policies," and 2) perpetuate old school psychoanalytical concepts which stated that psychiatrists must be "blank slates" and sit there and say nothing, and not coincidentally, not have personal lives either. That's not Freudian, by the way. It was more of a mid-century trend. It's still popular in certain institutions. I have never failed to notice that the people trying to get the residents to shut up on Facebook are the same ones that have positions of high power in certain institutions, but who are part of a dwindling minority within the field at large.

And as for the work life balance it's just so ironic and hypocritical. Ours always had a sexist tone. It was like: "for you women in the audience, here's how you can manage your part time suburban private practice and still have time for your husband and kids! And look at my giant ring and my giant mini-van outside - it's proof!" Every single one was like that.

Sorry for so many posts... back to the topic I hope!

 

[OldPsychDoc]

...
I kind of wish one of the very well known medschools could just be like F-this, we know how to train physicians we are going to train our physicians how we want to because we are the best in the world and drop all this extra BS documentation of every little thing. Granted I imagine a lot of this extra bureaucracy is being driven by some of the big name medschool types, but I can always dream.

Well it better be a well known med school with a BIG bankroll--because this is all basically being driven by the Joint Commission and Medicare, and the latter is funding 85% of your residency training...so saying F-this implies being ready to pick up the tab on your own training.

 

[Armadillos]

Well it better be a well known med school with a BIG bankroll--because this is all basically being driven by the Joint Commission and Medicare, and the latter is funding 85% of your residency training...so saying F-this implies being ready to pick up the tab on your own training.

I know your completely right, obviously not going to happen. In my dream it would be someone like Hopkins or Harvard who would would raise a ton of money and go out and do medicine training "their way".

On the more practical level related to funding training as you mention, I'm curious what percent of medical education costs are attributable to the huge administrative costs that go into meeting all these requirements. Seems like a massive amount of MD man hours go into this, not to mention all the extra non-MD admin assistants working on all this documentation. Then you have all these expensive clinical evaluation type setups schools are having to build for OSCEs, etc.

 

[hamstergang]

Ok first of all hamster gang, you have no idea if I "do what I'm supposed to do or not," or if I'm "ignoring" my work. And the last I heard, I can do whatever I want with my life. I can even spend it complaining!

I never said you didn't do your job, or that you couldn't complain. I just found it odd that you complained about your day and didn't bother to mention the actual psychiatry you were doing.

Now insomnia, low energy, etc. is by nature extremely boring to hear about. I bet there is even literature about the countertransference of psychiatrists towards depressed patients that would show, that depressed patients invoke a feeling of dreariness and hopelessness on the part of the psychiatrist. Anyone who claims it's "interesting" to listen to people talk about their low energy, etc. is weird, and should probably not be in a patient care position. I am sure I am not alone!! And there's your bread and butter of psychiatry!

This I do take issue with. I find it interesting to listen to patient talk about low energy and poor sleep, as well as many other issues they are experiencing. That doesn't make me weird or a poor fit to be caring for patients -- it makes me a psychiatrist. You clearly don't like psychiatry, but why do you find it odd that other psychiatrists actually do?

And it's not the individual patients I mind, it's doing the same thing all day and having no impact on the world, and often, no impact on the patients since our treatments are not exactly highly precise neurosurgical techniques with exactly defined effect rates, and the DSM is not exactly cutting edge science and mental health care is not exactly the priority of this nation. I say "no impact" not because I am being "negative" but because literally, I do not see a change in the world as of yet, and I do not see an overall improvement in the mental health of my patient population. Some get better, and others get worse. They cancel out. Hence: no impact.

Well I think I make an impact. But I also find my patients and the work interesting, so maybe I actually am.

But to clarify, on the inpatient unit what I would do is this: I would walk around the hallway in a manner called "rounding" and I would ask people how they slept, about medication side effects, if they're hearing voices, if they feel suicidal. On my face would be an expression of curiosity and concern. I would then proceed to a computer, usually one with numerous problems, where I reproduce these interesting comments in my notes. I would also choose from among the 50 or so standard medications of essentially unknown pharmacologic mechanism that we use, some appropriate treatment. Oh, and, lo and behold, I make "empathic" statements in which I "reflect back" the emotions they are expressing. Sometimes I would make "interpretations" and sometimes I would try to "motivate." Does that clarify things?

Maybe instead of being "empathic" and "reflect back," making "interpretations" and "motivating," you'd be better served by being empathic and reflect back, and by making interpretations and motivating.

 

[slappy]

Is nancysinatra the new vistaril?

 

[billypilgrim37]

Difference is Nancy needs a hug, and Vistaril needs a sportscar!

 

[OldPsychDoc]

Nancy's just what happens when decent people go to undeservedly "prestigious" residencies but refuse to drink the Kool-aid.

 

[daru1]

I see kids and adolescents. Of course I feel a lot more comfortable with that one year of fellowship under my belt.

 

[birchswing]

Look up Self Psychology or Object Relations. Some authors are Kernberg and Kohut. Also, I forget the author off the top of my head but he writes about the Intersubjective Third. Also, look into theNeurobiology of Attachment by Lou Cozolino (a professor of mine).

Thanks!

 

[smalltownpsych]

So to get back to the topic of this thread, it was about adult psychiatrists seeing kids. What I notice about this thread is that people are defending the fellowships because they find them "useful." Ok I would never challenge that, especially since I haven't done one. What I was trying to get at was, where's the data showing the outcomes improve with this model of training?

Because I'm sitting here thinking, wait, there is a huge shortage of child psychiatrists, there is a disincentive to go to fellowship which is loan interest accumulation, and right now, more and more kids are being seen by people who didn't even to go medical school! NPs, etc. So how can we possibly defend this system as being the only model we are willing to accept?

You might have a good point here. As a psychologist, it is up to me to determine my areas of competency and when to refer. We don't have a requirement to have a post-doc or internship that is specific to any population or area of specialty, unless you want additional certification (e.g., neuropsychologist). I would think that a psychiatrist should be able to monitor their level of competence with various populations and when to refer. If we create too many barriers for ourselves as doctoral providers, then we leave the door wide-open for mid-levels. The state that I live in is one of the most difficult to obtain licensure as a psychologist (it took me about a year and I was already licensed in another state) and the result is that the vast majority of the providers are LPCs and MSWs.

 

[shan564]

So to get back to the topic of this thread, it was about adult psychiatrists seeing kids. What I notice about this thread is that people are defending the fellowships because they find them "useful." Ok I would never challenge that, especially since I haven't done one. What I was trying to get at was, where's the data showing the outcomes improve with this model of training?

There will never be data to answer that question because you can't ethically design a study that will give you a reliable answer.

Because I'm sitting here thinking, wait, there is a huge shortage of child psychiatrists, there is a disincentive to go to fellowship which is loan interest accumulation, and right now, more and more kids are being seen by people who didn't even to go medical school! NPs, etc.

I think you could say the same thing about general psychiatry.
This isn't a perfect analogy, but if I had a stroke, I'd rather be seen by a neurology-trained NP than a neuroradiologist, even though neuroradiologists were probably rock stars in med school and probably know way more about the brain than a neuro-trained NP. Similarly, I think a child psych-trained NP knows more about treating autism than a psychiatrist who begrudgingly did child psych for 1 afternoon every week in 3rd year of residency.

 

[DD214_DOC]

Although there are many, the key difference with C/A specific training is the focus on development and systems. Although a child/teen may present with anxiety and depression, from what do said symptoms arise? It could be related to the child's natural developmental stage being at odds with the goals of the family system. The child's presentation may actually be a manifestation of the family's pathology. The list goes on and on.

The best example of this is something the OP mentioned. That there is no difference between a 17 year old and an 18 year old. You really wouldn't recognize that if you didn't understand where that adolescent patient is developmentally compared to what is developmentally normative for that age span.

 

[Therapist4Chnge]

Difference is Nancy needs a hug, and Vistaril needs a sportscar!

To be fair…sports cars solve most of life's problems.

 

[smalltownpsych]

Although there are many, the key difference with C/A specific training is the focus on development and systems. Although a child/teen may present with anxiety and depression, from what do said symptoms arise? It could be related to the child's natural developmental stage being at odds with the goals of the family system. The child's presentation may actually be a manifestation of the family's pathology. The list goes on and on.

The best example of this is something the OP mentioned. That there is no difference between a 17 year old and an 18 year old. You really wouldn't recognize that if you didn't understand where that adolescent patient is developmentally compared to what is developmentally normative for that age span.

I think you were criticizing the logic of there being no difference between a 17 year old and an 18 year old. Obviously, legal distinctions are not as crucial as developmental distinctions and anyone who knows a little bit of neuroscience should know that the frontal cortex is developing at a rapid rate during the teen years, number one; and number two, as you alluded to, there are also critical developmental challenges especially in regards to relationships that are occurring simultaneously. This is one reason why I enjoy working with adolescents so much. It is challenging and exciting work and they are definitely not the same as adults other than at a superficial physiological level.

*edit* For some of the same reasons, they are also not really children. Good luck treating them as such. The stats for suicide risk in teens and young adults regarding SSRIs show the error in that type of thinking.

 

[DD214_DOC]

Who said anything about treating an adolescent like a child?

 

[smalltownpsych]

Who said anything about treating an adolescent like a child?

I didn't mean to imply that you were and in fact I think we are both saying the same thing.