CAP fellowship questions

[bltzybltz]

I had some CAP fellowship questions:

1) is a CAP fellowship actually required to take on children as patients, or just "strongly recommended" (because of the training it provides)? What's stopping general psychiatrists from a child-focused private practice?

2) Are most CAP fellowships fast tracked (i.e. so that you can complete residency in 5 years) or is this only a subset?

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[hamstergang]

What's stopping general psychiatrists from a child-focused private practice?

Usually not wanting to. But also you'd be pretty lost as to how to practice properly. Your medical license lets you do surgeries even if you only do a psychiatry residency, so there's no legal barrier.

 

[wolfvgang22]

I had some CAP fellowship questions:

1) is a CAP fellowship actually required to take on children as patients, or just "strongly recommended" (because of the training it provides)? What's stopping general psychiatrists from a child-focused private practice?

2) Are most CAP fellowships fast tracked (i.e. so that you can complete residency in 5 years) or is this only a subset?

CAP not actively seeing children and adolescents here:

1. No
2. Yes.
3. You may not want to liability of seeing younger children without a fellowship, and insurance may not panel you as CAP anyway. Older teens are frequently seen by general psychiatrists. Younger kids get treated by the pediatrician until they can see a CAP most of the time.

 

[PikminOC]

Usually not wanting to. But also you'd be pretty lost as to how to practice properly. Your medical license lets you do surgeries even if you only do a psychiatry residency, so there's no legal barrier.

Np and psychologist can medicate all ages

 

[hamstergang]

Np and psychologist can medicate all ages

I'm not sure why that's relevant. Psychiatrists without a CAP fellowship can see all ages too, but I wouldn't recommend it for anyone without additional training.

 

[PikminOC]

I'm not sure why that's relevant. Psychiatrists without a CAP fellowship can see all ages too, but I wouldn't recommend it for anyone without additional training.

If those fools can do it I think a psychiatrist can. They have much more training.

 

[bltzybltz]

What kind of liability is added to your practice if you're an adult psychiatrist who takes on children?

 

[PikminOC]

What kind of liability is added to your practice if you're an adult psychiatrist who takes on children?

Less than if you supervise midlevels. At least it's the psychiatrist seeing the patients.

 

[bltzybltz]

Less than if you supervise midlevels. At least it's the psychiatrist seeing the patients.

I see lol. Is an adult psychiatrist who sees children unable to advertise themselves as a "Child Psychiatrist" unless they have completed the fellowship? I'm having trouble seeing what the CAP fellowship offers (beyond the necessary training to work with minors) from a legal standpoint if an adult psychiatrist if a regular psychiatrist can see all ages of patients and can call themselves an "All-Ages/Family Psychiatrist" or something.

 

[TexasPhysician]

You can legally see and treat anything, but your liability goes up the more you explore outside of your limited scope.

I could open up a sports medicine clinic tomorrow.

A lot of child psych is off-label. I know a well trained child psychiatrist that will testify against you if you choose the wrong SSRI without good reasoning when an adverse event happens. Some decent studies can determine which you “should” use by many child psych folk. For instance, there are “wrong” answers to which SSRI to use in a 9 year old that failed Prozac.

 

[bltzybltz]

You can legally see and treat anything, but your liability goes up the more you explore outside of your limited scope.

I could open up a sports medicine clinic tomorrow.

A lot of child psych is off-label. I know a well trained child psychiatrist that will testify against you if you choose the wrong SSRI without good reasoning when an adverse event happens. Some decent studies can determine which you “should” use by many child psych folk. For instance, there are “wrong” answers to which SSRI to use in a 9 year old that failed Prozac.

That makes sense. I personally don't plan on treating children without a CAP fellowship, and this reasoning (the gap in knowledge) solidifies that. Thanks!

 

[calvnandhobbs68]

You can legally see and treat anything, but your liability goes up the more you explore outside of your limited scope.

I could open up a sports medicine clinic tomorrow.

A lot of child psych is off-label. I know a well trained child psychiatrist that will testify against you if you choose the wrong SSRI without good reasoning when an adverse event happens. Some decent studies can determine which you “should” use by many child psych folk. For instance, there are “wrong” answers to which SSRI to use in a 9 year old that failed Prozac.

lol yeah basically almost ALL child psych is off label outside of ADHD.

OP as mentioned above yes, you can treat kids after a general psychiatry residency but basically nobody does. I find that most general psychiatrists don't want to because they don't want to deal with the families and you honestly don't get that much exposure during residency. Minimum child psych exposure is like 2 rotations (usually 1 inpatient and 1 longitudinal outpatient clinic). So yes, if you had to go to court over it, they'd probably rip right into the fact that you got a whole 1 inpatient month and 1 half day of clinic for a half day a year of child psych exposure in residency. It's not like FM where they see kids all the time in their outpatient clinic. You also don't have much exposure in terms of developmental outcomes/milestones, developmental disorders, common childhood comorbidities, dealing with school districts/CPS, 504 plans/IEPs, etc etc.

 

[Bartelby]

Child is different. When it comes to for example addictions, geriatrics, or C-L psychiatrists routinely treat those populations without a fellowship. For child, I'm not sure you could even get malpractice insurance coverage without the fellowship. Even if you do, you will be an easy target for lawsuits as you have the appearance right off the bat of practicing outside your scope (which, really, you would be).

I agree with the above that we (non-child psychiatrists) are likely better trained to treat children than many NPs who do it anyway. We all know, though, that as physicians we will be held to a different standard. Whether right or wrong, that's just how it is.

In short, if you want to practice CAP you need the fellowship.

 

[Merovinge]

This is not a question unique to psychiatry. General surgeons, neurosurgeons, urologists (maybe other surgical specialties, I'm not as familiar with the rest) can all technically operate on a 1 day old baby, but given all three have pediatric fellowships/board certification available (outside of the absolute most rural places) you will not see this occurring. Being able to do something and being trained to do something are very different things in medicine, it seems like we are the last bastion of people who actually understand this. You should practice what you are trained to practice and do the best thing for the patient in front of you, and when you can, for the population as a whole.

 

[clozareal]

You can legally see children/adolescents as a general psychiatrist. But if you get sued, the standard of care of seeing children and to a lesser degree adolescents is to be fellowship trained, bonus if you actually got a board certification in it.

Although much of the diagnostic nosology and skills you learn as a psychiatrist are helpful when treating kids, there's also a wide range of different skillsets when working with children. For adolescents, it might be similar to seeing young adults, but even then, treating adults can feel much different than treating minors. Here are a few ways that CAP training adds benefit on top of residency training off the top of my head:

• You'll need to incorporate play with young children for diagnostic evaluations and how to use it in treatment (play therapy) whereas in adults you most likely won't.
• You need to incorporate collateral from parents, teachers, caregivers, and other people because of the lack of insight that children/adolescents often have.
• You'll need to learn how to give informed consent to parents/guardians rather than the patient (although you'll also have to learn how to get assent from the patient in a developmentally appropriate way). If you have divorced/separated parents, this becomes more complicated. If those divorced parents disagree strongly, then this is a much more difficult task to treat the patient.
• Developmental disabilities such as intellectual disability and autism. These can lead to symptoms that can be non-responsive to medications but extremely responsive to behavioral or academic interventions.
• Treating hyperactive/impulsive subtype of ADHD, utilizing stimulants and non-stimulant options to treat ADHD and manage their side effects, although this is becoming more common in adults. You still have to know how it will affect developmental trajectory (height, weight, self-esteem, future substance use, future accidents, etc).
• You need to know how to navigate school systems including IEPs and 504s, the different private vs public vs charter vs non-public school options.
• Treating first episode psychosis or prodromal symptoms is much different than treating schizophrenia.
• Diagnoses are much less clear and treatment is often based on symptoms rather than an overt disorder.
• Irritability, temper tantrums, meltdowns, aggression are more common in children and treated differently than in an adult.
• Medications and interventions that work in adults may not be effective (or have the evidence base in the literature) in children/adolescents. This includes NAC for trichotillomania, TMS for depression, TCAs for depression, therapy vs meds for social anxiety disorder/OCD, etc. Knowing physiological differences in different age groups and weight based dosing for common medications.
• Kids are much more likely to respond to psychotherapy than medications, which is true for adults for certain conditions as well, but parents often don't like medicating their children and therefore psychotherapeutic approaches are more often utilized.
• How young? Will you see a 4 year old with separation anxiety disorder or evaluate for ASD in a toddler? What's the differential diagnosis for visual hallucinations of cartoon characters in an 8 year old (I've had 4 of these intakes in the past few months)?
• Navigating gender identity issues in this patient population and dealing with family structures that may or may not support it.
• Mandated reporting for child abuse and what constitutes as such. How to disclose this to the parents.
• Childhood trauma, neglect, and how to evaluate for associated symptoms and intervene on issues stemming from this.
• Dealing with conduct disorder, oppositional defiant disorder, disruptive mood dysregulation disorders.
• How to work with parents in parent management training, functional behavioral analysis (operant conditioning), and how to help parents set up a behavioral plan.
• Family therapy with parent/guardian and child. Supporting co-parenting and how to give advice on this for the benefit of the child.
• Working with parents/guardians on a safety plan after a suicide attempt is much different than working with an adult who may be living independently or with a significant other.

 

[PikminOC]

You can get sued for anything anytime and a hired gun will testify for each side.

 

[TexasPhysician]

You can get sued for anything anytime and a hired gun will testify for each side.

While true that you can be sued for anything at any time, few people have the resources and desire to drag out a lawsuit that they know they can’t win. You can eventually find a hired gun that’ll be on your side, but most good firms have trusted physicians that will review the case to let them know if the case is worth moving forward with. Attorneys can get in trouble themselves for over-billing and providing misleading data.

In the grand scheme of things, it costs little for the attorneys to have me review the records and let them know if I would have done differently. Selecting a medication first line with no documented reason that only has studies failing in that age group is a problem for that physician. It is sub-standard for a child psychiatrist. This alone can lead to a settlement even though I’ve never met the child. No testimony is needed as it won’t get to court. At other times, I’ve said I would do the same thing and the attorneys drop the case.

Attorneys only want to take civil cases that they think they will win. They don’t want to waste their time, except in rare instances where a client is willing to spend hundreds of thousands on a losing case (signing a document that says they’ve been informed of the likely outcome).

Malpractice cases aren’t easy to win in court, and especially in states with tort reform, attorneys can’t afford to waste $ on hired guns that’ll just say anything. Opposing attorneys can use past testimony against hired guns.

 

[michaelrack]

On inpatient positions, child fellowship is usually required for under age 12 or so. General psychiatrists can see adolescents.

 

[Merovinge]

You can get sued for anything anytime and a hired gun will testify for each side.

Sure this is technically true that any of us can be sued at any time. However, if you have one doc "seeing" 50 patients a day, "supervising" 4 APNs by signing off on un-read charts and another seeing 2 patients/hour who follows all best-practice guidelines and clearly documents rationale if there is ever deviation, I can 100% tell you who is both more likely to be sued and lose/settle a suit. There might be 1 universe where doctor B gets more lawsuits than doctor A but the best we can do is stack the odds in our and our patient's favor.

 

[PikminOC]

Sure this is technically true that any of us can be sued at any time. However, if you have one doc "seeing" 50 patients a day, "supervising" 4 APNs by signing off on un-read charts and another seeing 2 patients/hour who follows all best-practice guidelines and clearly documents rationale if there is ever deviation, I can 100% tell you who is both more likely to be sued and lose/settle a suit. There might be 1 universe where doctor B gets more lawsuits than doctor A but the best we can do is stack the odds in our and our patient's favor.

Which is why I only see patients myself.

 

[Stagg737]

Personal opinion: psychiatrists, psychologists, NPs, etc should not be seeing kids under 12 without specialized training. I feel comfortable treating most patients over 16 yo but personally I would not see anyone under 14 yo outside of emergencies.

 

[PikminOC]

Personal opinion: psychiatrists, psychologists, NPs, etc should not be seeing kids under 12 without specialized training. I feel comfortable treating most patients over 16 yo but personally I would not see anyone under 14 yo outside of emergencies.

Np and psychologist are "trained" to see 6 and above.

 

[hamstergang]

Np and psychologist are "trained" to see 6 and above.

This is a thread about a psychiatrist doing a child/adolescent fellowship. Why do you keep talking about nurses? None of us are going to become nurses.

 

[PikminOC]

This is a thread about a psychiatrist doing a child/adolescent fellowship. Why do you keep talking about nurses? None of us are going to become nurses.

I have a new thread on that I posted yesterday. Take a look. 10 k per week is what travel nurses are making.

 

[hamstergang]

I have a new thread on that I posted yesterday. Take a look. 10 k per week is what travel nurses are making.

Why is that relevant to us as psychiatrists? We're not nurses. Our pay and their pay are not based on the same things. This seems like a weird deflection by you.

 

[PikminOC]

Why is that relevant to us as psychiatrists? We're not nurses. Our pay and their pay are not based on the same things. This seems like a weird deflection by you.

Thanks for the free analysis

 

[Stagg737]

Np and psychologist are "trained" to see 6 and above.

And I have strong opinions about that as well, doesn't change that I don't think psychiatrists should be seeing small kids without specialized training.

 

[PikminOC]

And I have strong opinions about that as well, doesn't change that I don't think psychiatrists should be seeing small kids without specialized training.

Then who should see them? There's aren't enough cap. So pediatrician get stuck with this and they aren't trained in psych. So the patients are referred to midlevels? That makes no sense.

 

[Merovinge]

Then who should see them? There's aren't enough cap. So pediatrician get stuck with this and they aren't trained in psych. So the patients are referred to midlevels? That makes no sense.

There's already a three tier system in place for this in the US. Those with cash can get into a CAP virtually anywhere in the country (and 100% are able to virtually). Those with private insurance can get into see a CAP with some waiting in most urban cities and even some semi-rural areas or may commute for appointments and then do other appointments virtually in most parts of the country. This leaves the question of medicaid children and there is a huge dearth of CAP services available to them. If you are offering adult psychiatrists for that work, I would take them in most instances over peds and clearly over midlevels. If you are suggest adult psychiatrists see children at their cash practice or with private insurance, it's very unlikely to be about need and more about the adult psychiatrist trying to expand their patient pool which is driven by revenue and not humanistic desire to help kids.

 

[PikminOC]

There's already a three tier system in place for this in the US. Those with cash can get into a CAP virtually anywhere in the country (and 100% are able to virtually). Those with private insurance can get into see a CAP with some waiting in most urban cities and even some semi-rural areas or may commute for appointments and then do other appointments virtually in most parts of the country. This leaves the question of medicaid children and there is a huge dearth of CAP services available to them. If you are offering adult psychiatrists for that work, I would take them in most instances over peds and clearly over midlevels. If you are suggest adult psychiatrists see children at their cash practice or with private insurance, it's very unlikely to be about need and more about the adult psychiatrist trying to expand their patient pool which is driven by revenue and not humanistic desire to help kids.

Even the midlevels dont take medicaid....

 

[Stagg737]

Then who should see them? There's aren't enough cap. So pediatrician get stuck with this and they aren't trained in psych. So the patients are referred to midlevels? That makes no sense.

Imo young kids should either be seen specifically by CAP or at least evaluated by CAP and then returned back to Peds or gen psych once more stable. Or we need to make adjustments to have CAP consultants available in a collaborative care model. Imo being a CAP psychiatrist that only sees 14 and above is a waste of an education, at that point why bother with a fellowship CAP fellowship at all?

Even the midlevels dont take medicaid....

Yes, sadly reality does align with ideals or even minimal standards of care. Doesn't mean I think it's appropriate for mid-levels or gen psych to see 6-10 yo severely disordered children who've failed the first 3 steps of treatment...