Doing Peds in addition to Psych?

[serimeri]

I'm an intern here and I have really been enjoying my Pediatrics rotation. I feel like I am a much happier person around children. I still want to do Child Psychiatry but I also miss the medicine part of Pediatrics. I was wondering if anyone has done one of those combined programs that give you triple board certification or has any info on them? Is there any benefit to having the Pediatrics certification at all?

I love my program and my institution so much, but I don't think they have a combined program. I just feel like I am happier around kids.

Thank you

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[hamstergang]

I am not a triple boarder. Those that are may think it a good idea. But generally, I tend to hear that it doesn't make much sense -- in the end, you're likely just going to practice child/adolescent psychiatry. You end up missing out on some general psychiatry training compared to those of us who don't have the Pediatrics piece, which I think is a detriment (edit: I misread, maybe if you're already in psych then you wouldn't end up missing out, but then it would take you longer to finish).

but I also miss the medicine part of Pediatrics.

Not to sound annoying or defensive or whatever, but I want to know what you mean by this? I think it would be worthwhile for you to explore your thoughts on this and see how your perception actually matches up with reality as we see it. (edit again: seeing how you're in psych, I don't want to imply that you don't know what it's like. But, as an intern, things aren't the same as they will be later on. For me, the further I progressed, the more I learned, the more I understood the role of psychiatry in medicine and of medicine in psychiatry. Or something like that.)

 

[eli20]

Anytime I talk to anyone about double/triple boards I get the exact same advice - most people end up doing 1 thing and unless you have a very clear career plan more often than not it ends up being a lot of extra work and extra maintenance of certifications/etc for things you probably don't use much/at all.

 

[serimeri]

I am not a triple boarder. Those that are may think it a good idea. But generally, I tend to hear that it doesn't make much sense -- in the end, you're likely just going to practice child/adolescent psychiatry. You end up missing out on some general psychiatry training compared to those of us who don't have the Pediatrics piece, which I think is a detriment (edit: I misread, maybe if you're already in psych then you wouldn't end up missing out, but then it would take you longer to finish).


Not to sound annoying or defensive or whatever, but I want to know what you mean by this? I think it would be worthwhile for you to explore your thoughts on this and see how your perception actually matches up with reality as we see it. (edit again: seeing how you're in psych, I don't want to imply that you don't know what it's like. But, as an intern, things aren't the same as they will be later on. For me, the further I progressed, the more I learned, the more I understood the role of psychiatry in medicine and of medicine in psychiatry. Or something like that.)

I guess it's just the part of me that hates it when the social worker or medical students think that just because I'm a psychiatry resident it means that I can't adjust someone's blood pressure medication or give them advice about their CHF.

 

[vistaril]

I guess it's just the part of me that hates it when the social worker or medical students think that just because I'm a psychiatry resident it means that I can't adjust someone's blood pressure medication or give them advice about their CHF.

why would you adjust their blood pressure medicine? Wouldn't you be upset if they happened to see the primary care doctor and the primary care doctor decided to switch the patient from Lithium to Zyprexa when they were a patient of yours too? I know I would.....

 

[hamstergang]

I guess it's just the part of me that hates it when the social worker or medical students think that just because I'm a psychiatry resident it means that I can't adjust someone's blood pressure medication or give them advice about their CHF.

Ok, so what I hear you saying is that you miss the generalist part of medicine? I think it's important to phrase it like this as saying that you miss "medicine" implies that only general stuff is medicine, and that comes with certain connotations.

Every specialty, including general peds, ends up giving up parts of medicine in terms of things you will actively manage. If you do peds, you won't manage any but the more basic psych disorders and meds. If you do radiology you probably won't manage any conditions. This doesn't mean they aren't practicing medicine. So keeping in mind that you have to give stuff up, the question becomes what are you least willing to part with?

 

[FlowRate]

I guess it's just the part of me that hates it when the social worker or medical students think that just because I'm a psychiatry resident it means that I can't adjust someone's blood pressure medication or give them advice about their CHF.

I'm hearing that you want your abilities as a "medical" doctor to be validated in the eyes of others via an additional certification. But I think you might actually be saying that you want to be able to help your patients with unmet primary care needs, but are unsure whether you need additional credentialing to do so.

On the one hand, I've always been told that once you have your medical licence, you can practice real medicine. If you build a practice filled with patients who won't see their primary care doctor, you will probably be a value add by being willing to manage primary-care issues. On the other hand, I am unsure how things would work if you wanted hospital privileges/insurance coverage.

 

[vistaril]

I'm hearing that you want your abilities as a "medical" doctor to be validated in the eyes of others via an additional certification. But I think you might actually be saying that you want to be able to help your patients with unmet primary care needs, but are unsure whether you need additional credentialing to do so.

On the one hand, I've always been told that once you have your medical licence, you can practice real medicine. If you build a practice filled with patients who won't see their primary care doctor, you will probably be a value add by being willing to manage primary-care issues. On the other hand, I am unsure how things would work if you wanted hospital privileges/insurance coverage.

see, it is *IMPOSSIBLE* to build an outpatient practice of patients who can't access a primary care doctor. I-M-P-O-S-S-I-B-L-E. I'd like for someone on here to tell me how the hell someone is going to be seeing outpatients who can't access a pcp?

If you're seeing them in an insurance based outpt practice....well, they obviously can get a pcp.

If you're seeing them in a cash pay outpt practice.....well they likely have insurance and can get a pcp. and if they don't, well hell they are paying you cash so they could obviously pay a pcp cash too.

If you are seeing them in a cmhc or medicaid type setting, they have medicaid and while their options for pcps are going to be much more limited every area has at least some clinic who caters to this population. They may have to drive a bit and may have to see a midlevel, but still.

So what else is there? Who are these outpatients who can't access primary care? They DONT EXIST.

 

[clausewitz2]

see, it is *IMPOSSIBLE* to build an outpatient practice of patients who can't access a primary care doctor. I-M-P-O-S-S-I-B-L-E. I'd like for someone on here to tell me how the hell someone is going to be seeing outpatients who can't access a pcp?

If you're seeing them in an insurance based outpt practice....well, they obviously can get a pcp.

If you're seeing them in a cash pay outpt practice.....well they likely have insurance and can get a pcp. and if they don't, well hell they are paying you cash so they could obviously pay a pcp cash too.

If you are seeing them in a cmhc or medicaid type setting, they have medicaid and while their options for pcps are going to be much more limited every area has at least some clinic who caters to this population. They may have to drive a bit and may have to see a midlevel, but still.

So what else is there? Who are these outpatients who can't access primary care? They DONT EXIST.

Where are you that your local CMHC population has reliable access to motor vehicles? In this neck of the woods (which is not super urban, I promise) our no show rate approaches 100% when the weather messes up the city bus schedules.

 

[vistaril]

Where are you that your local CMHC population has reliable access to motor vehicles? In this neck of the woods (which is not super urban, I promise) our no show rate approaches 100% when the weather messes up the city bus schedules.

huh? If they can get transportation to a cmhc(for a psychiatrist to tinker with their bp meds), they could also get to a primary care office. If they don't have access to a car and require special transportation(ie an approved medicaid ride), they could use that transportation to get to their pcp as well.

Terrible argument. To the extent it is a passable argument, it would actually be a more reasonable one as to why primary care physicians should dinker with psych meds of this population....since it's probably more likely that special transportation services would be easier to access for primary care than mental health services.(partly because there are simply more primary care locations)

 

[clausewitz2]

[QUOTE/] huh? If they can get transportation to a cmhc(for a psychiatrist to tinker with their bp meds), they could also get to a primary care office. If they don't have access to a car and require special transportation(ie an approved medicaid ride), they could use that transportation to get to their pcp as well. [/QUOTE]

So I was responding to that bit when you said
[QUOTE/] They may have to drive a bit and may have to see a midlevel, but still. [/QUOTE]

Feel free to correct me, but that sounds an awful lot like you are saying you expect them to, you know, drive. Maybe you didn't mean that at all, but responding incredulously when someone responds to the literal content of your utterance is a tad excessive.

[QUOTE/]
Terrible argument. [/QUOTE]

I would challenge you to find an argument in my statement above that contains any argument beyond "medicaid patients frequently depend on the bus." As is I really don't know what argument you think I'm making, and acting is if my interpretation of the literal content of your utterance was totally unreasonable doesn't incline me to try and work it out.

My guess, to a first approximation, is: "Any model of practice that is not identical the model that I believe is fiscally optimal is impossible and does not exist in the world." This summarizes a fair number of other posts, I think.

[QUOTE/]
To the extent it is a passable argument, it would actually be a more reasonable one as to why primary care physicians should dinker with psych meds of this population....since it's probably more likely that special transportation services would be easier to access for primary care than mental health services.(partly because there are simply more primary care locations)[/QUOTE]

Putting aside the fact that case managers are typically working for mental health agencies and are much less common in primary care clinics that do not already have significant grant funding, I guess I would see the strongest argument for a psychiatrist managing baby general medicine in the context of folks who are sufficiently disorganized or impaired that routinely coming to one appointment every so often is a struggle. Add a second appointment on top of this and the results are not always great. I get what you're saying, though, and agree - in an ideal world everything would just be integrated and everyone who wanted one would have a patient, caring, and available primary care provider. When that happens I will buy you a beer.

 

[vistaril]

i still stand by the idea that if a patient has transportation difficulties that limit their overall number of trips, going to the pcp(especially if they have conditions like DM or HTN needing med mgt changes) is both going to take priority over going to psych in most cases and be more accessible than psych in most cases for this population. Within 10 miles of where I live there are > 12 clinics that see medicaid patients for primary care matters and only a few that see psych medicaid patients.

the "they may have to drive a bit" comment is going to likely be even more applicable for mental health than psych. If they are driving x number of miles to the pcp that takes medicaid, there is a good chance that they will have to drive > x number of miles to the mental health clinic taking medicaid.

As for the case manager part....if they have a case manager that could manage to get them transportation to the psych appt surely that same case manager could find a way to get them to a primary care office every so often.

I've seen hundreds(thousands?) of medicaid outpts.....many of them do have transportation struggles. I cannot recall a single one where I ever said "this person cant get to a primary care doctor but can get to me so I need to take over their bp meds". Hell(and Im just remembering this now)....for us to get paid you know who has to make the referral? Their PRIMARY CARE DOCTOR!!! All our medicaid patients are referred by the person that is already managing their blood pressure meds.....

So again, not to say the issue of access problems doesn't exist. But this twisted scenario where they(an outpt) have great access to me but not a pcp is highly highly unlikely to exist

 

[clausewitz2]

i still stand by the idea that if a patient has transportation difficulties that limit their overall number of trips, going to the pcp(especially if they have conditions like DM or HTN needing med mgt changes) is both going to take priority over going to psych in most cases and be more accessible than psych in most cases for this population. Within 10 miles of where I live there are > 12 clinics that see medicaid patients for primary care matters and only a few that see psych medicaid patients.

the "they may have to drive a bit" comment is going to likely be even more applicable for mental health than psych. If they are driving x number of miles to the pcp that takes medicaid, there is a good chance that they will have to drive > x number of miles to the mental health clinic taking medicaid.

As for the case manager part....if they have a case manager that could manage to get them transportation to the psych appt surely that same case manager could find a way to get them to a primary care office every so often.

I've seen hundreds(thousands?) of medicaid outpts.....many of them do have transportation struggles. I cannot recall a single one where I ever said "this person cant get to a primary care doctor but can get to me so I need to take over their bp meds". Hell(and Im just remembering this now)....for us to get paid you know who has to make the referral? Their PRIMARY CARE DOCTOR!!! All our medicaid patients are referred by the person that is already managing their blood pressure meds.....

So again, not to say the issue of access problems doesn't exist. But this twisted scenario where they(an outpt) have great access to me but not a pcp is highly highly unlikely to exist

You continue to seem to think I am arguing otherwise, and I am not sure why.

What I think may be an issue of access that goes that way is the patient may well have a more established and longer-standung relationship with a psychiatrist and prioritize those apptmts more.

 

[vistaril]

You continue to seem to think I am arguing otherwise, and I am not sure why.

What I think may be an issue of access that goes that way is the patient may well have a more established and longer-standung relationship with a psychiatrist and prioritize those apptmts more.

eh....I mean I guess it's possible. But I'd say it's 10x more likely that the patient is going to have a more established and longer lasting relationship with the pcp. After all, think about the context(a cmhc or other clinic geared towards low income or medicaid patients):

1) the patient was likely referred to the mh clinic by their pcp
2) these aren't long appointments(anyone who has worked in a cmhc type place knows this) built on close relationships between psychiatrist(or more likely psych np these days) and patient
3) there is a lot of provider turnover at these mh places(the patients don't even always see the same provider)

Now some of these things are also true of primary care offices that accept medicaid, but it's still much more likely that a patient will have a longer/more established and even closer relationship with their pcp in these cases that the psychiatrist working at the community mental health center.

But yeah, I'm sure somewhere it has happened before where a medicaid patient with limited transportation can only go to one doctor appt with any regularity and picks the MH one and thus their htn med regimen isn't going to be able to be adequately addressed by a pcp....but it's clearly going to be a very uncommon thing. Far more common will be the other direction(I see that sometimes with no shows)

 

[clausewitz2]

eh....I mean I guess it's possible. But I'd say it's 10x more likely that the patient is going to have a more established and longer lasting relationship with the pcp. After all, think about the context(a cmhc or other clinic geared towards low income or medicaid patients):

1) the patient was likely referred to the mh clinic by their pcp
2) these aren't long appointments(anyone who has worked in a cmhc type place knows this) built on close relationships between psychiatrist(or more likely psych np these days) and patient
3) there is a lot of provider turnover at these mh places(the patients don't even always see the same provider)

Now some of these things are also true of primary care offices that accept medicaid, but it's still much more likely that a patient will have a longer/more established and even closer relationship with their pcp in these cases that the psychiatrist working at the community mental health center.

But yeah, I'm sure somewhere it has happened before where a medicaid patient with limited transportation can only go to one doctor appt with any regularity and picks the MH one and thus their htn med regimen isn't going to be able to be adequately addressed by a pcp....but it's clearly going to be a very uncommon thing. Far more common will be the other direction(I see that sometimes with no shows)

Probably population dependent. I guess on the ACT team I was with a lot of folks knew and loved the psychiatrist they were assigned and the team was struggling to keep them going to PCPs.

Edit: I suppose they were also getting referred by local inpatient psych units or the state hospital, so a different pipeline entirely from what you are talking about.

 

[FlowRate]

see, it is *IMPOSSIBLE* to build an outpatient practice of patients who can't access a primary care doctor. I-M-P-O-S-S-I-B-L-E. I'd like for someone on here to tell me how the hell someone is going to be seeing outpatients who can't access a pcp?

If you're seeing them in an insurance based outpt practice....well, they obviously can get a pcp.

If you're seeing them in a cash pay outpt practice.....well they likely have insurance and can get a pcp. and if they don't, well hell they are paying you cash so they could obviously pay a pcp cash too.

If you are seeing them in a cmhc or medicaid type setting, they have medicaid and while their options for pcps are going to be much more limited every area has at least some clinic who caters to this population. They may have to drive a bit and may have to see a midlevel, but still.

So what else is there? Who are these outpatients who can't access primary care? They DONT EXIST.

I was thinking more along the lines of patients who could but choose not to see a PCP (typically more CMHC population). I don't know how many patients fit that description, but I've heard the concept mentioned at least once by a regular contributor on this forum in the past.