Any forensic psychiatrists in these forums?

[UnicornDemon]

So, I've recently considered going into med-school with the intent of becoming a psychiatrist, but I'm a little bit nervous about those "fifteen-minute med-checks". When I heard about forensic psychiatry, though, my interest was definitely piqued. I'm not sure what the work entails, but I'm hoping to go into psychiatry to do work that is meaningful and challenging.

Are there any forensic psychiatrists out there who can tell me what their work entails?

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[notdeadyet]

Meaningful and challenging psychiatry work is definitely not the domain of forensic psychiatry. You can find it in private practice, public, inpatient, addiction, child, etc. Many domains in psychiatry don't have 15 minute med checks. The length of follow-up appointments is not dictated by the field or government and many practices have 20 or 30 minute follow-ups.

Follow-ups are a necessary part of longitudinal care. If you want a field in psychiatry that doesn't focus so much on longitudinal care, you can look at inpatient, emergency, forensics, etc.

Forensic work is fascinating and you can learn more about it by doing a good search (use the Search link at the top of the page, select Advanced Search, then type "forensic" in the search box, check Titles only, and restrict it to Psychiatry). There have been a lot of threads that discuss what forensic psychiatrists do.

ADDENDUM:
Unicorn- You're really putting the cart before the horse here. In the past few weeks, you've started threads indicating an interest in Anesthesiology, Cardiology, Radiology, Pharmacy, Pathology, and PM&R, in addition to Psychology, Dentistry and Pharmacy. These are radically different fields and specialties. I'd suggest learning more about what kind of career you want for yourself before focusing on minutia like whether or not to subspecialize in something down the road. At the end of the day, the difference between a dentist, doctor, and pharmacist is a big choice. Once you decide doctor you need to decide on psychiatry vs. something else. Once you decide on psychiatry, you can consider forensics. Forensics is just an added skillset onto the foundation of well-practiced psychiatry.

 

[UnicornDemon]

Meaningful and challenging psychiatry work is definitely not the domain of forensic psychiatry. You can find it in private practice, public, inpatient, addiction, child, etc. Many domains in psychiatry don't have 15 minute med checks. The length of follow-up appointments is not dictated by the field or government and many practices have 20 or 30 minute follow-ups.

Follow-ups are a necessary part of longitudinal care. If you want a field in psychiatry that doesn't focus so much on longitudinal care, you can look at inpatient, emergency, forensics, etc.

Forensic work is fascinating and you can learn more about it by doing a good search (use the Search link at the top of the page, select Advanced Search, then type "forensic" in the search box, check Titles only, and restrict it to Psychiatry). There have been a lot of threads that discuss what forensic psychiatrists do.

ADDENDUM:
Unicorn- You're really putting the cart before the horse here. In the past few weeks, you've started threads indicating an interest in Anesthesiology, Cardiology, Radiology, Pharmacy, Pathology, and PM&R, in addition to Psychology, Dentistry and Pharmacy. These are radically different fields and specialties. I'd suggest learning more about what kind of career you want for yourself before focusing on minutia like whether or not to subspecialize in something down the road. At the end of the day, the difference between a dentist, doctor, and pharmacist is a big choice. Once you decide doctor you need to decide on psychiatry vs. something else. Once you decide on psychiatry, you can consider forensics. Forensics is just an added skillset onto the foundation of well-practiced psychiatry.

Sorry, I wasn't trying to imply that the work of psychiatrists in other settings isn't meaningful. But, based on two encounters I've had with psychiatrists in the past, I'm afraid to pursue this field. Both of them just handed me anti-depressants/anxiety meds after a three minute interchange.

Then again, I'm sure highly motivated psychiatrists can find meaningful work in the right setting, as you stated.

And yes, I know I've been spending a lot of time on these forums. I'm just worried about landing myself in a career that I won't be happy with so I'm doing research on the options available to me.

 

[whopper]

I'm a forensic psychiatrist. A drawback with medschool if you want to go into this field is you're going to spend years doing stuff not even closely directed to this field and will have to tolerate this, Feel free to ask questions.

 

[MLT2MT2DO]

I'm a forensic psychiatrist. A drawback with medschool if you want to go into this field is you're going to spend years doing stuff not even closely directed to this field and will have to tolerate this, Feel free to ask questions.

Do you still do much/any forensic's work now that you're in academia?

 

[vistaril]

Sorry, I wasn't trying to imply that the work of psychiatrists in other settings isn't meaningful. But, based on two encounters I've had with psychiatrists in the past, I'm afraid to pursue this field. Both of them just handed me anti-depressants/anxiety meds after a three minute interchange.
.

So is it a 3 minute check, or a 15 minute check? Thats a big difference....

What I'm seeing more and more of is practices(especially agency types) that spend a total of 15 minutes with a patient, but of that 15 minutes only 3 of them(as in your case)
involves face to face with the psychiatrist....much of the rest may involve going over a beck depression inventory or whatever with a sw before seeing the psych.

 

[whopper]

Yep. I do about 8 hours of forensic lectures a year for fellows/residents/faculty.

I do private cases, maybe a total of about 30 hours a year though I could do more if I wanted.

Attendings and residents call me all the time about forensic related questions.

There's a monthly forensic journal club and I'd attend if it were for my darned two kids!

 

[UnicornDemon]

So is it a 3 minute check, or a 15 minute check? Thats a big difference....

What I'm seeing more and more of is practices(especially agency types) that spend a total of 15 minutes with a patient, but of that 15 minutes only 3 of them(as in your case)
involves face to face with the psychiatrist....much of the rest may involve going over a beck depression inventory or whatever with a sw before seeing the psych.

The first psychiatrist was one who visited my college and saw students in 30 minute blocks. She only talked to me for around 10 minutes. I expected her to do therapy for the next 20 minutes so I sat in the room and tried to talk to her about depression and anxiety issues I faced, but gave up and left when her apathetic attitude made me realize she was only there to prescribe meds.

The next psychiatrist is a private practice owner who schedules patients for 30 minute evals and 15 minute follow-ups. We usually talk for the full 15 minutes. I was exaggerating when I stated that they were 3 minute interchanges.

 

[KLPM]

So, I've recently considered going into med-school with the intent of becoming a psychiatrist

Correct me if I am wrong but I think you said you only just finished high school?

There will be plenty of time in medical school to decide what specialty you will enjoy. It's not a bad thing to be enthusiastic about becoming Dr X but no one can tell you if you are going to be miserable in field X or not. People frequently post on here about "if specialty X is right for me" and a lot of the time the realistic answers are "get into medical school first" or "do a rotation in that field". We don't know what will interest you. We don't know what kind of work will motivate you to get out of bed every morning. Maybe during medical school you will discover an interest in paediatric neuro-gastro-oncological hepatic transplant surgery for all we know.

My philosophy is that you really need to experience a field first hand to know if you will like it. You need to experience the bread and butter cases, the work hours, learning new material etc. What do you like about psychiatry? What do you like about radiology? What do you like about pathology? What do you like about anaesthesia?

edit: apologies for the intrusion psychiatry people. I am going to slowly back away.

 

[markglt]

whopper, i'm an off cycle resident, will be a third year resident in dec., considering forensics..have not done a rotaxn in it yet.
I'm intereseted in Addiction as well, but there is no fellowship at my institution and I dont wanna "start over" someplace else. I was thinking maybe to stay at my instiftuion and do forensecis, hop on as jr faculty part tme or something. Aside from beig comfy with/ liking the legal system, what is the draw or intellectual stimuli for one interested in forensics. Would one use that skill set if they did 75% outpatient office work with 25 % IP consults. Is it a waste to do the fellshp. it if not 100%... thoughts on a combo with addiction??

 

[whopper]

Even if one were to never do forensic psychiatry in private practice, IMHO, doing fellowship makes one a much better clinical psychiatrist overall.

Violence assessments and malingering are just two examples of areas that forensic psychiatrists, if you are in a good program, will get good training that is highly relevant in clinical psychiatry. (Disclaimer, some fellowships will not teach this well at all).

I kick out people all the time that I have good reason are malingering and because I have the training in detecting it, I know if I were ever sued, I could give a heck of a lot more in my defense than to simply just say I had a gutt-feeling. I could base in on actual legal standards and incorporate psychological testing. The non-forensic attendings sometimes call me up on a suspected malingerer case, asking me what to do to make sure they cover themselves.

I also get called frequently from attendings on difficult cases where the law could get involved. E.g. one patient, while psychotic, lights fires. Given that matches and lighters are readily available, he felt discharging the patient would be like putting her out with the equivalent of a loaded gun. He wanted to make sure the patient was discharged in a manner where it would become very clear that in a legal regard, he did his responsibilities.

But aside from this, forensics teaches several facets of what is clinical psychiatry that is not taught in general residency such as why psychiatry has to do treatment plans but other fields don't, critically think on a level far more intense on usual clinical decision making (because you have to be prepared to have someone tear you apart in court on every decision made), proper documentation on progress notes to avoid law suits, marrying our talents better with psychology, legal expectations in clinical practice that most residents aren't taught (e.g. the exact legal requirements you must do in terminating a patient from practice), among plenty of other stuff.

Addiction psychiatry marries well with forensic psychiatry because most forensic psychiatry patients from experience have addiction problems. Although I don't have an addiction fellowship, I do have Suboxone training and a lot of my college work in my psychology major was on addiction so I do have more knowledge than a lot of psychiatrists in the area and it has worked out for me. The university, for example, often times asks me for help on addiction cases even though there is an addiction fellowship already there, and I've been asked to be a consultant on several private forensic psychiatry cases where drug use in involved.

If you want to do both fellowships, I wouldn't consider it a waste at all.

Outpatient marries well with private forensic psychiatry cases because you'll sometimes have to clear your schedule to appear in court or take time off from clinical work to focus on a private case. If you inpatient, you'll always have to be at work no matter how tough your private case is unless you use vacation time off. There are some exceptions, but in general except it to not marry well.

A benefit I have where I'm at is the department has a forensic fellowship attached so they do cooperate with us in this regard. E.g. one of the forensic psychologists I work with has specific time everyday set aside to him so he could do private cases though the university gets a big cut of the money he brings in.

 

[markglt]

A lotta good points, always apprecieted sir..

 

[SomeDoc]

Bumping an old thread. Anyone have experience on managing an active practice with a forensic practice? How challenging is it to balance the two? What kinds of scheduling arrangements are most likely (examples off the top of my head: 4 days outpt work with 1 day/week focused on forensic casework, or alternatively, two hours daily dedicated to forensic work)?

 

[marcbarton]

Bumping an old thread. Anyone have experience on managing an active practice with a forensic practice? How challenging is it to balance the two? What kinds of scheduling arrangements are most likely (examples off the top of my head: 4 days outpt work with 1 day/week focused on forensic casework, or alternatively, two hours daily dedicated to forensic work)?

I do not have this kind of experience but I could put you in touch with a Psychiatrist who does. He's worked in Atascadero and other prominent correctional facilities.

 

[whopper]

Managing outpatient schedules can be challenging if you have acute patients. You simply cannot clear your schedule easily when you have a patient that is doing terrible but it not bad enough for hospitalization. You could, however, clear your schedule except for the tougher patients, leaving you more hours open for your forensic practice.

Managing outpatient schedules is like playing Tetris. Every few minutes to hours a patient calls you, and you have to fit them into an open spot. It has to match their schedule and yours. After you do private practice for quite some time, your ratio of acute/stable patients becomes less and chronic patients can usually be told that they don't have to see you for weeks to months.

IMHO, if working on an easy forensic case such as a capacity evaluation to undergo a trial, such cases can be done in just a few hours tops, you can have a specific section of your week blocked off. Usually arrangements can be made with the local court to have them see you on specific days. The court will usually be very cooperative because they'll be very much in need of your services. On the other hand if you do a major forensic case such as a murder, you could be working on it several hours a day, every day, for weeks to even months. Then even after you do the report, you might not have to go to court for weeks. Again it's like Tetris. You have to actively manage your schedule. If you have plenty of acute patients, expect it to be like Tetris with the pieces falling very fast. If you don't have many acute patients it'll be like Tetris with the pieces falling slowly.

 

[SomeDoc]

Thanks for the replies. Speaking of competency evals, I hear the ones requested from the court aren't reimbursed very well. Interest aside, is it really worth it from a financial perspective to do these over seeing patients.

 

[whopper]

I can't tell you if it's worth it or not because the going rates will vary by locality. Also some docs are better at doing such evaluations quickly. Beginning of fellowship it took me about 5-6 hours to do even an easy one. By the end of the year the easy ones took me about 30 minutes to an hour. Another factor is some courts frankly don't seem to care if their mentally ill defendants don't get a fair trial and are then locked-up without treatment. The ones that care will treat you with more respect and usually higher pay.

 

[SomeDoc]

Appreciate the info. On a somewhat tangential note, I recently saw an old document with a diagnosis on a defendant performed by a community evaluator, where the condition neither made sense, nor was a condition that existed in the dsm. The sad thing is the court really had no idea about the quality of the work they were getting from this supposed expert. My guess is that these things would probably happen less if the court were to hire formally trained forensic psychs.

 

[whopper]

Happens all the time.

I had one guy I evaluated and I was convinced he had no Axis I mental illness other than substance abuse. The guy had over 15 admissions where he was labelled as schizophrenic.

I went through every single admission--the entire record on each one. There is one one mention, ONLY ONE of any signs of psychosis. It was a one word mention of auditory hallucinations with no description whatsoever. We all know that some lazy docs just say that to back up their diagnosis.

Sherlock Holmes once said something to the effect of (and I don't remember the exact quote), "Scotland Yard comes up with the conclusion, and then tries to make evidence try to fit it. We're supposed to look at the evidence and make the conclusion fit that."

Each time his case went to court and the court accepted the schizophrenia dx.

What was going on for real: The guy had one admission, he was physically intimidating, low IQ, and would attack others for their food. Each time he did so, they labelled him as agitated, gave him an antipsychotic and stated that was further evidence of psychosis. They'd let him go after he didn't attack someone for about 3-4 days.

After one admission, the rest were dominoes. The next doctor just saw his history, believed from the outset that the guy had schizophrenia (At least on the chart), and then just managed it like the above.

I even called some of the prior doctors and they even told me they never saw him exhibit any real signs of psychosis. I asked them why they continued a bogus schizophrenia dx and they gave me various answers such as "who cares? he's off the street for a few days," "well you know, it makes the day go easier," "the police dumped him on us and if I let him go I knew he'd attack someone in the community so I had to keep him there at least a few days to make sure. By the end of his stay I had to have a dx or else we couldn't bill."

Just to prove with 100% certainty he didn't have it, I made sure he got no meds on the psych unit. He was without psychosis for two months with no medications.

I had to go to the witness stand and basically say that every single doctor that worked on the patient, some of them working in the same facility basically just put on a dx of convenience and not one that was real and that some of them even admitted this to me.

Thankfully those doctors weren't in court that day, and hospital's forensic director didn't tell them I was pretty much bashing them on the stand. It stayed in court and didn't leave it. The administration and the court believed me and my stock went up with them and I didn't get any fallout.

It's unfortunate but I've never yet been in a place where I haven't seen this type of thing go on. Some places less, some places more but I've seen it everywhere.