C-l...

[AnnTaylor]

Well, I'm about to start residency...I know things may change between now and four year from now, but as a med student, I really liked doing consults. I think part of the reason was enjoying seeing fresh cases at a greater rate, not always having as much background on the patient (more mystery to decipher), and moving along quickly. The downfall, well maybe the patients are a little more unpredictable since you don't know much about their psych hx necessarily. I also understand bogus consults and power struggles with IM are another downfall of psychosomatics (not that I mind a bogus consult that one gets paid for?).

As far as I can tell, C-L/Psychosomatics fellowships come up on this board as one of the fellowships for those who want to mix in a little more medicine into their psych training....I'm not sure just how much medicine one gets in an extra year of training, but based on your experience or exposure, would you agree that I can just do primarily consult work w/o the fellowship after residency?

Not sure how I'd get my name out in the consult "niche" right out of residency or what the job market is like for strictly consult psych, but it seems there isn't a huge salary difference for those who did the fellowship.

Neuropsychiatry is another contender for me, but doesn't excite me as much diagnostically.

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[Doc Samson]

Well, I'm about to start residency...I know things may change between now and four year from now, but as a med student, I really liked doing consults. I think part of the reason was enjoying seeing fresh cases at a greater rate, not always having as much background on the patient (more mystery to decipher), and moving along quickly. The downfall, well maybe the patients are a little more unpredictable since you don't know much about their psych hx necessarily. I also understand bogus consults and power struggles with IM are another downfall of psychosomatics (not that I mind a bogus consult that one gets paid for?).

As far as I can tell, C-L/Psychosomatics fellowships come up on this board as one of the fellowships for those who want to mix in a little more medicine into their psych training....I'm not sure just how much medicine one gets in an extra year of training, but based on your experience or exposure, would you agree that I can just do primarily consult work w/o the fellowship after residency?

Not sure how I'd get my name out in the consult "niche" right out of residency or what the job market is like for strictly consult psych, but it seems there isn't a huge salary difference for those who did the fellowship.

Neuropsychiatry is another contender for me, but doesn't excite me as much diagnostically.

Could you do CL work without the fellowship? Yes. Do I think you should? No. Probably the most valuable year of training I had. Well worth the investment of the extra year if that's what you're planning on doing with your career.

 

[SomeDoc]

Could you do CL work without the fellowship? Yes. Do I think you should? No. Probably the most valuable year of training I had. Well worth the investment of the extra year if that's what you're planning on doing with your career.

Why is this? What do we not learn during residency that is otherwise taught in a C/L fellowship (I ask this in earnest, not rhetorically)? Why would it be recommended that Psychiatrists, who are first and foremost physicians, get additionally trained in a fellowship to do what they should be competent in practicing? I never really understood the reasoning for a "consultation/liaison" (or should I rather say, psychosomatic) fellowship training. If such a fellowship is truly necessary as implied, for the practice of competent psychosomatic medicine, it represents a serious deficiency in current Psychiatric residency curriculum or focus.

 

[Doc Samson]

Exposure, exposure, exposure. Current ACGME requirement for CL is what? 2 months? Given the infinite number of combinations of medical illness and psychiatric symptoms/diagnoses, that's just not enough time to see enough of the more complicated stuff.

Let's take transplant as an example. Transplant patients are often anxious and sometimes depressed. They may become psychotic or manic depending on their immunosuppressive regimen. They are often delirious post-operatively. Now - how would your management differ depending on the organ transplanted. Hearts are different than lungs which are different from kidneys which are different from livers and so on - in terms of the medications that you'd choose, the potential medical complications (hypoxia, uremia, hyperammonemia) and the existential issues that the patient is facing. We haven't even mentioned the required psychiatric evaluation before the transplant.

How much exposure does a typical resident get to PNES? How about frontal lobe epilepsy that the neurology resident is certain is PNES? A CL fellowship in a hospital with a vEEG epilepsy monitoring unit could expose you to several of these cases a day. Now let's throw in the "psychiatric mimics" that show up in the scope of CL. How many cases of a limbic encephalitis (paraneoplastic or otherwise) would you expect to see in 2 months as a resident? How about Hashimoto's encephalopathy? CJD? Kluver-Bucy syndrome? Cerebellar cognitive affective syndrome? PRES?

Sure, your 2 months in residency could prepare you to take decent care of garden-variety delirium, steroid induced mania, depression comorbid with a medical issue, etc. Then again, a decent medicine residency should also prepare you to take care of these things. The CL fellowship prepares you to take care of the more uncommon issues that are likely to stump folks without that training.

 

[AnnTaylor]

Exposure, exposure, exposure. Current ACGME requirement for CL is what? 2 months? Given the infinite number of combinations of medical illness and psychiatric symptoms/diagnoses, that's just not enough time to see enough of the more complicated stuff.

Let's take transplant as an example. Transplant patients are often anxious and sometimes depressed. They may become psychotic or manic depending on their immunosuppressive regimen. They are often delirious post-operatively. Now - how would your management differ depending on the organ transplanted. Hearts are different than lungs which are different from kidneys which are different from livers and so on - in terms of the medications that you'd choose, the potential medical complications (hypoxia, uremia, hyperammonemia) and the existential issues that the patient is facing. We haven't even mentioned the required psychiatric evaluation before the transplant.

How much exposure does a typical resident get to PNES? How about frontal lobe epilepsy that the neurology resident is certain is PNES? A CL fellowship in a hospital with a vEEG epilepsy monitoring unit could expose you to several of these cases a day. Now let's throw in the "psychiatric mimics" that show up in the scope of CL. How many cases of a limbic encephalitis (paraneoplastic or otherwise) would you expect to see in 2 months as a resident? How about Hashimoto's encephalopathy? CJD? Kluver-Bucy syndrome? Cerebellar cognitive affective syndrome? PRES?

Sure, your 2 months in residency could prepare you to take decent care of garden-variety delirium, steroid induced mania, depression comorbid with a medical issue, etc. Then again, a decent medicine residency should also prepare you to take care of these things. The CL fellowship prepares you to take care of the more uncommon issues that are likely to stump folks without that training.

So the overlap with neuro and IM becomes more prominent in one's practice. And how much of a power struggle does one have vs neuro and IM? Also, some EEG training apparently at some CL fellowships? Certainly not at the level of an epileptologist? Interesting as far as who they would call first for the consult and whether this varies based on what kind of a relationship they have with the psych department (including level of respect at some programs).

 

[Doc Samson]

So the overlap with neuro and IM becomes more prominent in one's practice. And how much of a power struggle does one have vs neuro and IM? Also, some EEG training apparently at some CL fellowships? Certainly not at the level of an epileptologist? Interesting as far as who they would call first for the consult and whether this varies based on what kind of a relationship they have with the psych department (including level of respect at some programs).

The answer to all of the above questions is entirely dependent on the hospital in which you train or practice. For example, where I trained their was a VERY oppostional relationship between Neuro and Psych, but where I work now we're very collegial.

In terms of epilepsy, you don't necessarily get trained to read EEGs, but you do get training in the phenomenology and semiology of seizures. Asynchronous bilateral motor activity with pelvic thrusting and preserved consciousness does not necessarily mean it's PNES.

 

[Manicsleep]

The answer really is exposure.
Not just to CL but also to the more medical/neuro related specialties, inpatient, geriatrics, ER, addiction and forensic psychiatry.

I do a fair bit of CL but I did about 6 months of CL and was the teaching senior in 3 of those months. I also had a lot of exposure to forensics, did 2 addiction rotations and had heavy ER exposure. My sleep fellowship gave me a lot of exposure to neuro, medicine and pediatrics.

I think the CL folks have an upper hand in certain things if they practice purely CL (however I have an advantage in certain areas as well) however those that practice a mix like me just have the advantage of the fellowship. Its the same with geriatrics.

RE: EEGs, I did teach the psych CL fellows and psych residents basic EEG but not enough to interpret studies (I am not qualified to teach that).

 

[nitemagi]

Many good C/L fellowships will also get sub-subspecialty exposure in areas you rarely see in a general residency.

Such as psychoderm, psycho-oncology, transplant (as mentioned above). That's the biggest draw for me to a fellowship, the ability to work towards carving out a specific niche.

 

[235750]

How many cases of a limbic encephalitis (paraneoplastic or otherwise) would you expect to see in 2 months as a resident? How about Hashimoto's encephalopathy? CJD?

The training you described sounds incredible!

But, I don't understand how a fellowship could get you that much exposure to such rare diseases in only 1 year. There's been < 200 cases of Hashimoto's enceph. in the entire world, and CJD in the US is about 200 a year (just studied these for step 1).

Does one cover a region of hospitals across a state? Do you do much traveling to other areas of the country (or world) as part of the training?

 

[AnnTaylor]

The training you described sounds incredible!

But, I don't understand how a fellowship could get you that much exposure to such rare diseases in only 1 year. There's been < 200 cases of Hashimoto's enceph. in the entire world, and CJD in the US is about 200 a year (just studied these for step 1).

Does one cover a region of hospitals across a state? Do you do much traveling to other areas of the country (or world) as part of the training?

If you're at a highly reputable institution where zebras are sent, you will see all that. interesting though that doc sampson's examples are somewhat neuro-centric and I wonder if some C-L fellowships emphasize the interface of psych and neuro vs psych and medicine.

 

[Doc Samson]

The training you described sounds incredible!

But, I don't understand how a fellowship could get you that much exposure to such rare diseases in only 1 year. There's been < 200 cases of Hashimoto's enceph. in the entire world, and CJD in the US is about 200 a year (just studied these for step 1).

Does one cover a region of hospitals across a state? Do you do much traveling to other areas of the country (or world) as part of the training?

Not sure where you get the numbers on Hashimoto's - I've seen 2 cases this year. Just because folks don't write an article, it doesn't mean it's not happening.

Location can be fairly important for CL. If you train at a major national/international center (think MGH, Mayo, etc.) then unusual cases will be transferred to your hospital. These are also the places that the very wealthy will travel to from all over the world. Bed number counts too - you're going to see more interesting cases in a 900 bed hospital than in a 150 bed hospital.

 

[Doc Samson]

If you're at a highly reputable institution where zebras are sent, you will see all that. interesting though that doc sampson's examples are somewhat neuro-centric and I wonder if some C-L fellowships emphasize the interface of psych and neuro vs psych and medicine.

My neuro-centric bias has more to do on where I practice (where we have more neuro/neurosurg ICU beds than medical/surgical ICU beds) than on where I trained.

 

[235750]

I read a metaanalysis about the enceph manifestation, but now that I am home looking at the paper, I realize it says there are 176 reported cases. So, as it's not a reportable disease, I would imagine you are right, that there have only been 176 cases studied. Which isn't a lot really, sounds like an easy publication for you! Only 8 cases were children, so bonus if your pts were toddlers

I see words like 'psychosomatics' and 'psychopharmacology' used in psychiatry training and it makes me scratch my head. It just feels like an improper partitioning of material that should be incorporated into all residency programs (as Somedoc suggested). It's all psychiatry, why use words like that? In residency I should be learning about psychosomatics every day, right? IT seems like a fellowship in psychosomatics should just be called 'more psychiatry exposure'. Or C/L, i guess, sounds better too

Anyway thanks again Doc samson, sounds like you have a very stimulating professional life

 

[nitemagi]

I see words like 'psychosomatics' and 'psychopharmacology' used in psychiatry training and it makes me scratch my head. It just feels like an improper partitioning of material that should be incorporated into all residency programs (as Somedoc suggested). It's all psychiatry, why use words like that? In residency I should be learning about psychosomatics every day, right? IT seems like a fellowship in psychosomatics should just be called 'more psychiatry exposure'. Or C/L, i guess, sounds better too

Funny, they had this discussion in the Presidential address this year at the American Psychosomatic Society, and what the term "Psychosomatic" really means and sends the right message. For them it was a bit different since it's largely an organization of researchers, but still relevant to this discussion.

 

[Doc Samson]

I read a metaanalysis about the enceph manifestation, but now that I am home looking at the paper, I realize it says there are 176 reported cases. So, as it's not a reportable disease, I would imagine you are right, that there have only been 176 cases studied. Which isn't a lot really, sounds like an easy publication for you! Only 8 cases were children, so bonus if your pts were toddlers

I see words like 'psychosomatics' and 'psychopharmacology' used in psychiatry training and it makes me scratch my head. It just feels like an improper partitioning of material that should be incorporated into all residency programs (as Somedoc suggested). It's all psychiatry, why use words like that? In residency I should be learning about psychosomatics every day, right? IT seems like a fellowship in psychosomatics should just be called 'more psychiatry exposure'. Or C/L, i guess, sounds better too

Anyway thanks again Doc samson, sounds like you have a very stimulating professional life

I think my job is the most fun thing you can legally earn money to do.

In terms of the "psychosomatics" thing, blame the ABMS. When the first application for subspecialty status was submitted, I believe the first choice was consultation-liaison psychiatry, but the ABMS rejected it since "role" (i.e. as a consultant) couldn't define a subspecialty. Next up was general hospital psychiatry, which was rejected because "location of practice" couldn't define a subspecialty. Third and final choice was psychosomatic medicine, which was accepted.

 

[notdeadyet]

In terms of the "psychosomatics" thing, blame the ABMS. When the first application for subspecialty status was submitted, I believe the first choice was consultation-liaison psychiatry, but the ABMS rejected it since "role" (i.e. as a consultant) couldn't define a subspecialty. Next up was general hospital psychiatry, which was rejected because "location of practice" couldn't define a subspecialty. Third and final choice was psychosomatic medicine, which was accepted.

That's interesting background. I wondered about that.

Out of curiosity, do C&L folks try to avoid the term "psychosomatic medicine?" In our department, I've never heard anything mentioned more specifically than "I'm from psychiatry" but I heard medical students on two occasions mention they were from "psychosomatic medicine" and both times the patient's bristled. I imagine it's a loaded term for a lot of patients.

 

[billypilgrim37]

We have a consult attending who always walks into the patient room and bellows "Knock, knock! It's psychiatry!" I wouldn't recommend this if you did not have a thick Russian-accent tenor voice, but it sure works for him.

 

[Manicsleep]

That's interesting background. I wondered about that.

Out of curiosity, do C&L folks try to avoid the term "psychosomatic medicine?" In our department, I've never heard anything mentioned more specifically than "I'm from psychiatry" but I heard medical students on two occasions mention they were from "psychosomatic medicine" and both times the patient's bristled. I imagine it's a loaded term for a lot of patients.

Thats interesting. I wonder why. I have never used the psychosomatic medicine introduction but I wouldn't expect that response.
What were the demographics of the patients?

 

[digitlnoize]

I would expect that response. To most laypeople, the term psychosomatic means "it's all in your head" and the doctor thinks you're crazy.

 

[Manicsleep]

I understand that but I would think that psychiatric would be more disturbing. Why does psychosomatic mean anything more instead of less? If I told my lay friends that term, the most common response would be "whats that?"

 

[notdeadyet]

So does psychiatric though. Why would psychosomatic mean anything more?

I think if a psychiatrist walks into a patient's room, the patient might interpret the visit as a concern about their mood or mental health. For a lot of laypeople, I think they interpret "psychosomatic" to mean "there's nothing physically wrong with you." I can see how a visit from a consult from a "psychosomatic" doctor could lead patients to feel their primary team feels they don't have any real physical ailments. When I rotated on PSM, I mentioned it to a friend, who replied "oh, to find the fakers, huh?"

The patients were asian and white, both 50's-60's. Didn't know them well to guess any demo info beyond that.

 

[Manicsleep]

I see. Well I usually just say your regular doctor asked me to talk to you about your -insert problem- and they are usually ok.

I won't be getting fancy with the psychosomatic lingo though. Good to know.

 

[wholeheartedly]

I would expect that response. To most laypeople, the term psychosomatic means "it's all in your head" and the doctor thinks you're crazy.

There are quite a few MDs with this mindset too...

 

[Pershing]

I'm a PGY-2 resident. This question is directed towards Doc Samson and anyone who knows about the psychosomatic fellowships. Based on their websites, it seems that psychosomatic fellowships are organized in 1 of 2 ways: 1) inpatient consults throughout the entire year with several half-days of various C-L clinics (e.g. psycho-oncology, HIV, transplant, primary care) longitudinally (example is NYU http://psych.med.nyu.edu/education/consultation-liasion-fellowship); or 2) discrete blocks of consult experiences, e.g. several months of inpatient consults, then one month of transplant, then two months of outpatient consults, etc. (example is Mayo http://www.mayo.edu/msgme/residenci...atic-medicine-fellowship-minnesota/curriculum). What are the advantages and disadvantages of each set-up? Also, how does MGH organize their psychosomatic fellowship? Their website doesn't delineate this. Thanks.

 

[Sushirolls]

Exposure to complex cases really makes the field and as previously pointed out (Mayo, MGH)where you train will get that for you. I want to also draw attention to Cleveland Clinic. The service at our program has a phenomenal Transplant psychiatrist, Dr. Coffman, with decades of experience who is the fellowship director. There are multiple C/L teams to cover the hospital. Zebras are in no short supply. We have seen fatal familial insomnia, several delusional parisotosis cases, and most every neuro/psych illness you can think of. This 1000+ bed hospital system never stops! If C/L is your thing, Cleveland Clinic should be on your list.

 

[strangeglove]

I see. Well I usually just say your regular doctor asked me to talk to you about your -insert problem- and they are usually ok.

I won't be getting fancy with the psychosomatic lingo though. Good to know.

Always ask the primary MD to tell the patient that you will be coming and why. This accomplishes 2 functions: it introduces you as a consultant and not someone who is going to ship the
patient off to the loony bin (though that may be the ultimate outcome); it also provides a nice test of long-term memory. You may the begin your interview with: "Hi, I'm Dr. X from psychiatry. Did your primary Dr. Y tell you I was coming to see you?". That way, even if they were not told/don't remember, you are still identified as a consultant. Patients have all sorts of fantasies about why a psychiatrist is there to see them. In the CL setting, it's always best to orient them to reality.

 

[NoNoNoNo]

If you're at a highly reputable institution where zebras are sent, you will see all that. interesting though that doc sampson's examples are somewhat neuro-centric and I wonder if some C-L fellowships emphasize the interface of psych and neuro vs psych and medicine.

Yeah, I saw two cases of CJD on my two weeks of neuro consult as a med student.