Psychiatry: Is it worth it?

[W19]

There is more money in general medicine for people who want to work hard and be efficient though. Bringing the same number of hours and efficiency to inpatient medicine, for example, and I really believe I'd make 40 percent more. You would have to juggle the right sort of hospitalist contracts that allowed for flexibility of course.

You really think you could have made 0ver 600k/year if you were a FM/IM doc working 60 hrs/wk?

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[Frazier]

You really think you could have made 0ver 600k/year if you were a FM/IM doc working 60 hrs/wk?

Yeah, that's a tough sell.

 

[erg923]

Not necessarily. Patients choose to pursue treatment. They choose to take their medications. Self agency (IMO) is inherent in the choices we make. How we act, and how we choose to respond to a situation. Taking medication is a choice, and therefore can be a daily reminder of choosing to pursue health.

How would it be "counter" therapeutic?

If one assigns sx improvment to medication(s), rather than their own sense of mastery, to me, this is disempowering. And I have heard that sentiment from countless patients as well. Probably the last thing one wants to reinforce in most psychiatric patients. "Countertherapetic" in my mind does not mean it doesn't provide symptom relief. Although I certainly have doubts about that as well in all but relatively severe cases given the overwhelmingly inconsistent, and relatively poor, effect sizes in the literature. The poster I chastised about having no faith in antidepressants may not be that far off, he had just reached that conclusion in a very unscientific way.

I also very much share concers pointed out by SPLIK numerous times regarding how chronic depression is frequently an adverse effect of long-term ingestion of antidepressants at high dosages (El-Mallakh, Gao, & Jeannie Roberts, 2011).

 

[Dharma]

If you are ambitious and talented, I would recommend you go into a more high powered field. Opportunities and respect and really outstanding in the top tier specialties. Otherwise psychiatry is fine if you want a comfortable lifestyle and easily manageable cerebral workload.

Ambitious and talented people should go into the field they can see themselves enjoying the most, period. Even if it's psychiatry or primary care. True respect comes from actions; all else is superficial.

 

[smalltownpsych]

Not necessarily. Patients choose to pursue treatment. They choose to take their medications. Self agency (IMO) is inherent in the choices we make. How we act, and how we choose to respond to a situation. Taking medication is a choice, and therefore can be a daily reminder of choosing to pursue health.

How would it be "counter" therapeutic?

Everyday we see patients looking for the "easy" way to improve their lives. Often the medication is a false hope. This is especially so for the non-severe psychiatric cases although my friend with schizophrenia who takes his meds is well aware of the limitations of those and the relative importance of taking care of himself socially, mentally, physically, and spiritually.
To get this back to the original topic, I would imagine that the hardest part of being a psychiatrist would be to not give a patient a medication. I know not being able to prescribe is a challenge in my own practice at times, but it also removes the problem of focusing on the medications to the exclusion of more important factors.

 

[vistaril]

You really think you could have made 0ver 600k/year if you were a FM/IM doc working 60 hrs/wk?

there is no doubt in my mind.....I'd juggle different hospitalist-like contracts with midlevel help. Some weeks would be more than 60 and some weeks would be less(due to the 7/7 nature). it would take some work to arrange the contracts and gigs but it is definitely doable. What you guys must understand is that people who obtain inpatient contracts(whether in psych or IM) don't always sit around from 7to7(or 8 to 5 in a M-F psych inpatient contract) and twiddle their thumbs and drink coffee with 'the treatment team'. At least the ones who want to make real money don't.

And let me just say that there is NOTHING WRONG at all with an inpatient psychiatrist or internist who likes to do that stuff.....meaning sit around and shoot the breeze with the social workers and nurses and the rest of the team throughout the day as it ticks by, but that's not the way to maximize your income.

 

[OldPsychDoc]

Everyday we see patients looking for the "easy" way to improve their lives. Often the medication is a false hope. This is especially so for the non-severe psychiatric cases although my friend with schizophrenia who takes his meds is well aware of the limitations of those and the relative importance of taking care of himself socially, mentally, physically, and spiritually.
To get this back to the original topic, I would imagine that the hardest part of being a psychiatrist would be to not give a patient a medication. I know not being able to prescribe is a challenge in my own practice at times, but it also removes the problem of focusing on the medications to the exclusion of more important factors.

"It takes 30 seconds to say 'Yes', but 30 minutes to say 'No'."

 

[nitemagi]

If one assigns sx improvment to medication(s), rather than their own sense of mastery, to me, this is disempowering. And I have heard that sentiment from countless patients as well. Probably the last thing one wants to reinforce in most psychiatric patients. "Countertherapetic" in my mind does not mean it doesn't provide symptom relief. Although I certainly have doubts about that as well in all but relatively severe cases given the overwhelmingly inconsistent, and relatively poor, effect sizes in the literature. The poster I chastised about having no faith in antidepressants may not be that far off, he had just reached that conclusion in a very unscientific way.

I also very much share concers pointed out by SPLIK numerous times regarding how chronic depression is frequently an adverse effect of long-term ingestion of antidepressants at high dosages (El-Mallakh, Gao, & Jeannie Roberts, 2011).

Both sides have truth to them. I don't prescribe in many cases, and do a great deal of therapy. A sense of agency and mastery I have not found to be specific to therapy. Some ppl don't feel mastery in therapy, even when they get better. Some ppl do view their use of meds as a form of mastery, because they identify a problem and use an available tool. There's a value judgment inherent in the idea that mental problems must be fixed through the mind directly. I think that's extreme.

This is not just my opinion. It is the opinion of my patients. Some definitely dislike that they require the medication for their symptoms. Many I get off of medications over time. However others really like their medication, and tell me they feel good about it because they "know what to do" if their symptoms come on. It's a tool. Not always my preferred one, of course, but one some patients do.

 

[smalltownpsych]

"It takes 30 seconds to say 'Yes', but 30 minutes to say 'No'."

There's a value judgment inherent in the idea that mental problems must be fixed through the mind directly. I think that's extreme.

It's statements like these that keep me invested in this site and sad that I have not met more psychiatrists in real life who were as thoughtful as many on this board. The psychiatrists that I have known seem to take the opposite stance that mental problems must be fixed chemically which is the other extreme. They diagnose my patients with Borderline Personality Disorder as Bipolar and then start chasing their symptoms like a game of whack-a-mole. These are the patients that have been tried on almost every combination of meds we got and are still as screwed up as they were when they were 16. If they are over 40 by the time I get to them, then they are like zombies with all the spark gone. Is it our treatment or their lifestyle that creates the burned out borderline?

I think one of the things that makes this career so worth it (whether from the psychiatric side or the psychological) is the fact that we have made so many recent advances and yet we still have so much work to do. The more answers we get just seems to raise more questions and in some fields of medicine you can try to ignore the intersection between the bio-psycho-social and just treat one aspect with varying degrees of efficacy, but that intersection is our home address.

 

[erg923]

There's a value judgment inherent in the idea that mental problems must be fixed through the mind directly.

I disagree, as its an empirical question, right? What approach truely helps one get better, not just "feel better." Ethically, I am in the business of helping people be better, not just feel better. If I only attempt the latter, then I feel I have not really done my job.

 

[F0nzie]

I think it's important to give credit where credit is due. If you repeatedly see symptoms relapsing in the context of poor med adherence damn right we are giving the medicine credit. On the other hand some patients give the medicine too much credit and I have to stop them and remind them of their efforts.

 

[nitemagi]

I disagree, as its an empirical question, right? What approach truely helps one get better, not just "feel better." Ethically, I am in the business of helping people be better, not just feel better. If I only attempt the latter, then I feel I have not really done my job.

I WHOLEHEARTEDLY agree. But doing better is a different metric than sense of agency, and doing better doesn't require a sense of agency.

 

[PikminOC]

If one assigns sx improvment to medication(s), rather than their own sense of mastery, to me, this is disempowering. And I have heard that sentiment from countless patients as well. Probably the last thing one wants to reinforce in most psychiatric patients. "Countertherapetic" in my mind does not mean it doesn't provide symptom relief. Although I certainly have doubts about that as well in all but relatively severe cases given the overwhelmingly inconsistent, and relatively poor, effect sizes in the literature. The poster I chastised about having no faith in antidepressants may not be that far off, he had just reached that conclusion in a very unscientific way.

I also very much share concers pointed out by SPLIK numerous times regarding how chronic depression is frequently an adverse effect of long-term ingestion of antidepressants at high dosages (El-Mallakh, Gao, & Jeannie Roberts, 2011).

There can be numerous other reasons for chronic depression as well.
While I work much like nitemagi in terms of therapy and/or medications, I also see many patients for whom therapy with their particular therapist has failed and no improvement, or even increase in their symptoms and underlying illness have occurred.
This can happen with any practitioner.

 

[Shikima]

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[jettavr6]

nice....Im going to do over 400 but Im having to hustle to do it. No true pp positions either.

Over 400K for an inpatient gig?

 

[heyjack70]

Relevant(ie non copied and pasted) part of Progress note(say an inpatient on day 4 with schizoaffective dx admitted for being agitated/psychotic/whatever): denies avh. Still some paranoia related to neighbors possibly following him. Denies ior. No si. Mood is 'fine'. Denies side effects from meds. Sleep, energy, appetite all 'ok'. Staff reports he hasn't appeared agitated last 24 hrs and no major incidents.
Mse: copied and pasted(may alter a word or two)
Assessment: copied and pasted(may alter a word or two)
Plan: increase Risperdal to 4mg qhs
(Some other stuff in the daily plan copied and pasted)

That shouldn't take more than a minute. Notes should be a VERY SMALL allotment of your total clinical time.

Is that a 99231 or 99232?