State of the business: a "psychiatrist" without a residency

[birchswing]

I've been looking for a new psychiatrist and have expanded my search to more urban areas. I came across one who sounded more personable and only takes self-pay, which interested me. He advertises himself as a "residency-trained psychiatrist."

I looked him on the Board of Medicine site and found that he was kicked out of two psychiatric residencies. One time for not showing up to major portions of the training and one time for a compulsive habit of watching pornography in front of other students.

He has only been in practice for several years but he has several reprimands from the state and is required to be in therapy in order to practice psychiatry.

This is the most extreme case I've come across of someone who is still practicing. Should he be allowed to call himself a psychiatrist if he never completed a residency? And isn't it awfully audacious to call yourself "residency trained"? Not to mention stupid. The only reason I looked him up was because he advertised himself as residency trained and I thought: why would someone mention something that is a given? I could take canoe lessons at Harvard and call myself Harvard-trained, I suppose.

I came across another psychiatrist I had been considering who has been reprimanded 5 separate times (over a period of 12 years) for prescribing herself Ambien and Aderall and also giving controlled substances to family members. Each time she is ordered to go to an inpatient detox program. How is that she gets so many second chances?

My former psychiatrist had his license revoked entirely. He was in a drunk driving accident and also found guilty of prescribing himself Ambien. If I had reported him to the state, he would have also been guilty of medical abandonment (he left the practice without notice--this was years before DUI). He was supposed to report to jail for 30 days (it was 6 months with most suspended) but fled to Pakistan instead. From what I could tell his license was revoked for not finishing the inpatient treatment he was supposed to do and for fleeing the country--not for the prescribing or drunk driving, which given the other state reprimands they would have probably given him a pass on.

The more I look around for psychiatrists, the more I keep coming up with these notices on the Board of Medicine site. What's weird is that the only inpatient facility for psychiatry near me is designed specifically for medical professionals and in several of the cases I found (including the one involving my former psychiatrists), the psychiatrists were referred there. The program specializes in helping people re-license and dealing with "the advanced defense mechanisms" of medical professionals.

It just seems pretty awful to me that these are the psychiatrists working in my area and that they keep getting so many second chances. And it seems pretty backward that the only inpatient facility in my town is specifically designed for doctors and helping them keep their licenses.

Part of me thinks this goes back to the debate I was having in another thread about how much of an investment a medical education is. It seems to me that once people have gone through medical school and residency they're treated as a very valuable product that can't be sacked no matter how poor the product. If you think of a doctor as a business and realize that you put about $300,000 (this is a guess, including undergraduate, not including opportunity costs obviously) into one and that there aren't many available, I can see why state boards are both sympathetic to the doctor for the investment the doctors have made and to the public for a lack of other doctors if you were to sack all the bad ones.

How many more people would be doctors, including psychiatrists, if they never had thoughts such as: Can I afford medical school? It's too big of a risk. What will I do will all that debt?

Instead we have eager beavers from foreign countries willing to fill spots that Americans aren't or we have trust-fund kids who somehow squeak through medical school and don't even complete a residency.

I wrote before that there would be more competition at the market-place level if you had tax-funded medical education. But I recently learned that there's more competition in Sweden at the medical school level because the education is free (it's also free for and open to competition from international students).

So, we both have less competition in the market (a dearth of doctors in psychiatry) and in applying to medical school (the pool is only of those who can afford debt).

If our system were more competitive would we have twice-kicked-out-residency, having completed no residency, under state-ordered therapy "psychiatrists"? Before doing this research I didn't even know you could be licensed as a doctor without a residency, but I found out you can depending on the state.

I see people on this board worried about competition from NPs. You should apparently be worried about doctors who aren't really doctors, as well.

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[PikminOC]

You may wish to read this thread:
http://forums.studentdoctor.net/thr...udent-of-degree.1118717/page-12#post-16161008

 

[hamstergang]

He advertises himself as a "residency-trained psychiatrist."

I looked him on the Board of Medicine site and found that he was kicked out of two psychiatric residencies.

Reminds me of this:

http://xkcd.com/1096/

 

[shan564]

I think we have too much of a tendency to protect each other in the medical field, even when the person being protected might be harming people. Just a few hours ago, I was seeing a patient who wanted a "second opinion" and I was initially reluctant to point out the suboptimal components of her regimen until I learned that it was only suboptimal because she hadn't followed the prescribed uptitration schedule... at which point I was more than happy to point out that I wanted to make the same change that her primary psychiatrist wanted to make and that she should follow his instructions.

 

[nitemagi]

Like any normal distribution, there are outliers. I have not seen psychiatrists be any more flagrant than other specialties, in my experience. Just read the california medical board newsletter for the reprimands of the quarter.

http://www.mbc.ca.gov/Publications/Newsletters/

The exception, of course, is people who go into psychiatry to "figure themselves out."

 

[Shikima]

The exception, of course, is people who go into psychiatry to "figure themselves out."

..and here I thought it was for the bling!

 

[freemontie]

Medical school admissions in the US is actually very competitive and is certainly not open to only those with rich parents (nearly everyone I've met has financed all or the majority of their education with debt). I am willing to bet this has less to do with US psychiatrists than with people in general (meaning flawed people sometimes obtaining positions of influence). Even the country you negatively compared us to, Sweden, has cases like this, which would have never occurred in our background-check-heavy culture.

 

[heyjack70]

..and here I thought it was for the bling!

for the groupies

 

[birchswing]

Medical school admissions in the US is actually very competitive and is certainly not open to only those with rich parents (nearly everyone I've met has financed all or the majority of their education with debt). I am willing to bet this has less to do with US psychiatrists than with people in general (meaning flawed people sometimes obtaining positions of influence). Even the country you negatively compared us to, Sweden, has cases like this, which would have never occurred in our background-check-heavy culture.

Fair points. I've been working on the assumption that you need a fairly well-off family to take on that much debt, but I guess since they're student loans it's not affected by credit history (?). Anecdotally however, I went to a high school where I didn't know of anyone who didn't go off to college and I feel that is because of both the emphasis put on education by the students' parents but also the parents' socioeconomic status. I suppose it's possible for someone of no means to take out loans for both undergraduate school and medical school, but it would be much more difficult (for one you'd have to either take out more loans for living expenses or you would have to work while attending school).

BTW, the article you linked to was very interesting. It raises interesting questions about what happens to people who commit serious crimes after being released from prison. I think I would draw a line at becoming a doctor when the crime in question is murder. Sweden is not a utopia, of course, and I hope I didn't make it sound that way. I lived there when I was quite young and it very much influenced my world view because of the stark differences I saw between it and the US. I'm sure if I were living there now I would probably more quickly point out faults in Sweden than the US (one such that you can see in the article is that the police are not very good at finding criminals in Sweden--petty robbery is not uncommon and the police are not often terribly effective--I would argue in the US there is better detective work although we are too enthusiastic in putting people in jail or executing them).

 

[Doctor Bagel]

I believe psychiatrists do have a higher rate of being disciplined than other specialties. Of course the ABPN is also happy to produce something showing that board certification is associated with less disciplinary issues. The relationship between academic struggles and disciplinary actions is interesting. We're historically an academically weaker crew (not all of us, but we remain one of the least competitive specialties).

Psychiatrists in Trouble: Licensure Actions Involving ABPN ... https://www.uic.edu/com/mcme/presentations/juul_042110.ppt

I've got to admit that I find disciplinary actions fascinating and read my state board reports regularly. The things some people do in medicine are absolutely amazing -- there are people in our field who are entirely antisocial. I've met some of them.

Side topic re: wealth and medicine, most physicians do come from higher socioeconomic backgrounds but not the highest. I'd say most of my peers are from upper middle class backgrounds. Lots of people including me funded their education all on their own, though, which can mean a lot of debt.

 

[OldPsychDoc]

Fair points. I've been working on the assumption that you need a fairly well-off family to take on that much debt, but I guess since they're student loans it's not affected by credit history (?). Anecdotally however, I went to a high school where I didn't know of anyone who didn't go off to college and I feel that is because of both the emphasis put on education by the students' parents but also the parents' socioeconomic status. I suppose it's possible for someone of no means to take out loans for both undergraduate school and medical school, but it would be much more difficult (for one you'd have to either take out more loans for living expenses or you would have to work while attending school).

BTW, the article you linked to was very interesting. It raises interesting questions about what happens to people who commit serious crimes after being released from prison. I think I would draw a line at becoming a doctor when the crime in question is murder. Sweden is not a utopia, of course, and I hope I didn't make it sound that way. I lived there when I was quite young and it very much influenced my world view because of the stark differences I saw between it and the US. I'm sure if I were living there now I would probably more quickly point out faults in Sweden than the US (one such that you can see in the article is that the police are not very good at finding criminals in Sweden--petty robbery is not uncommon and the police are not often terribly effective--I would argue in the US there is better detective work although we are too enthusiastic in putting people in jail or executing them).

..or just shooting them to save the trouble of a trial...

 

[digitlnoize]

The questionable actions of psychiatrists aside, this does raise an interesting question that I've thought about many times during residency:

Is the shortage of psychiatrists bad enough that we don't *need* to do residency anymore to get patients?

Given the looming shortages of both PCP's and psychiatrists, perhaps the medical field should question whether residency actually makes doctors more competent, or produces better outcomes than non-residency trained physicians. Has this ever been studied? Would 4 years of general psychiatry practice after medical school result in an equally competent doctor as 4 years of residency, all other things considered? Obviously in this case we had someone with some issues, but I'm talking about for the average medical school graduate. It's also worth pointing out that PA's and NP's don't have to do a residency and can simply enter practice after their (shorter) schooling is completed.

Given how dire the shortage is, don't we owe it to our patients, our community, and ourselves to actually show that the increased length of training actually serves a purpose?

"But digitlnoize, without supervision, the new medical school idiot graduates would make too many mistakes and kill patients." Yeah, maybe. Although I would argue that we're already doing that now, just in academic hospitals, and the outcomes probably wouldn't change much. (Yes, I know we're "supervised", but trust me, it's limited.)

The point is (and a brief lit search seems to confirm this) that we don't KNOW. We don't (to my knowledge) have data showing that residency trained physicians provide better care than non-residency trained physicians with similar experience and similar "temperament" (i.e. you can't compare residency trained physicians and non-residency trained physicians who were kicked out of residency for behavioral, psych, or performance problems, as that's not an accurate comparison. I'm talking about a good resident vs someone who would have been a good resident but just didn't.)

I want to be clear (because I'm sure someone *vistaril* will misunderstand me) that I'm not saying we should abolish residency training. I'm saying that we should compare the outcomes and then decide if it's worth keeping or not.

 

[Mass Effect]

My thought is that residency is important to turn out competent sole practitioners. However, I do think that there should be a choice about whether or not someone wants to complete residency after med school to practice. If someone wants to be a psychiatrist and doesn't want to complete residency, I think they should be able to do so in the role of midlevel with a board-certified psychiatrist supervising, much the same as PA/NP. It gives those who don't match an option at least.

 

[nitemagi]

I would argue that practicing without residency increases the adverse outcomes. I'd say there's a decent bit of data from IOM that lesser training is correlated, maybe even causing more treatment errors. As has come up in the psychology prescribing thread -- if you don't know the problems you won't look for them.

Furthermore, there's already enough problems that get swept under the rug. I'd argue we need higher standards not lower.

 

[PikminOC]

My thought is that residency is important to turn out competent sole practitioners. However, I do think that there should be a choice about whether or not someone wants to complete residency after med school to practice. If someone wants to be a psychiatrist and doesn't want to complete residency, I think they should be able to do so in the role of midlevel with a board-certified psychiatrist supervising, much the same as PA/NP. It gives those who don't match an option at least.

So then why not ANY field like this?
Why are you pointing to psychiatry specifically?

 

[digitlnoize]

My thought is that residency is important to turn out competent sole practitioners. However, I do think that there should be a choice about whether or not someone wants to complete residency after med school to practice. If someone wants to be a psychiatrist and doesn't want to complete residency, I think they should be able to do so in the role of midlevel with a board-certified psychiatrist supervising, much the same as PA/NP. It gives those who don't match an option at least.

That's my thought too, but I'm not sure. I haven't seen data on it, and I doubt there is any. If it exists it would likely be comparing people who couldn't match or couldn't complete residency to people who did match and did complete residency. Already biased.

I'm not 100% sure that if you took solid medical school graduates who could match well, put them through a 1 year internship to get a license, then had them spend 3 years as a mid-level" in the community that they'd have significantly worse outcomes than someone who completed a normal academic residency.

 

[freemontie]

That's my thought too, but I'm not sure. I haven't seen data on it, and I doubt there is any. If it exists it would likely be comparing people who couldn't match or couldn't complete residency to people who did match and did complete residency. Already biased.

I'm not 100% sure that if you took solid medical school graduates who could match well, put them through a 1 year internship to get a license, then had them spend 3 years as a mid-level" in the community that they'd have significantly worse outcomes than someone who completed a normal academic residency.

"spend 3 years as a mid-level"? So they get 3 years of supervision after internship? Basically you want to be a resident - but with more lee-way and pay?

If you want to decrease the education time to PCPs or Psychiatrists, I would say there are easier ways that gutting residency. The most obvious being instituting the system prevalent in most of the developed world where medical school is entered straight out of secondary school. There's about 3 extra years of general education college requirements or non-medically-relevant biology that most US pre-meds take. That almost certainly wouldn't decrease the resulting practitioner's effectiveness.

 

[hamstergang]

"But digitlnoize, without supervision, the new medical school idiot graduates would make too many mistakes and kill patients." Yeah, maybe. Although I would argue that we're already doing that now, just in academic hospitals, and the outcomes probably wouldn't change much. (Yes, I know we're "supervised", but trust me, it's limited.)

I don't trust you that the supervision is limited because that doesn't fit with my experience. I learned by observing and by making mistakes that never made it to the patient because it went through an attending first.

Also, if you kill a patient when on your own, you probably won't learn as much from it than if you have an attending helping to explain what you missed. So obviously I think residency is important. Bad care can be harmful, at times worse than no care at all.

 

[PikminOC]

Decreasing residency or undergrad won't change anything anyway.
The number of slots each year is the same...

 

[Doctor Bagel]

Honestly I'm not as up to date on this as I should be, so if anybody's got studies, please share them. My perception, though, is that we have not done a good job demonstrating the connection between all the training that we do versus say nurse practitioners and improvement in patient outcomes. We certainly have not done a good job in convincing the public of this. It seems like more of our claims center solely around how much more training we get without really showing that the increased training is beneficial.

Personally I feel as if residency training is hugely beneficial -- I think that's the thing our training offers that really sets us apart. I'm not sure, though, that I couldn't gain the same skills working provided I had the opportunity to seek out supervision. I'm also not sure about much benefit from all the detail we had to learn in basic sciences (and hey, I liked that stuff and those years of school). Medical school could probably be cut to at least 3 years, I think, although some of the downtime (summers, 4th year) are psychologically nice to have.

As for realistic options of going out there without residency, I think state medical boards are going to increasingly make this harder for us. My state board implies that they watch you more closely if you're not board certified (not just not board eligible). My worry is that midlevels are going to take over much or our turf because there are so few of us and people kind of forget that we exist. But then, I'm a worrier.

 

[Indodo]

The state boards will watch the non-boarded docs closely but then allow NPs, PAs and psychologists to prescribe willy nilly.
It would be funny if it wasn't so depressing.

 

[Shikima]

for the groupies

You know what they call psychiatry groupies?

 

[Indodo]

Lawsuits?

 

[Shikima]

I was thinking borderlines but that works too.

 

[Doctor Bagel]

The state boards will watch the non-boarded docs closely but then allow NPs, PAs and psychologists to prescribe willy nilly.
It would be funny if it wasn't so depressing.

It doesn't make a lot of sense, does it? It seems weird in the world of all this intrusion on our work by people with less training, our certifying people have decided to amp up how much we should be trained. More emphasis on board certification and fellowships. Family medicine residencies that are 4 years instead of 3.

 

[Mass Effect]

So then why not ANY field like this?
Why are you pointing to psychiatry specifically?

Um, because we're in the psychiatry forum on a thread specifically discussing psychiatry without a residency?

 

[Shikima]

It doesn't make a lot of sense, does it? It seems weird in the world of all this intrusion on our work by people with less training, our certifying people have decided to amp up how much we should be trained. More emphasis on board certification and fellowships. Family medicine residencies that are 4 years instead of 3.

In Canada, FP residency is only 2 years long while Psych is 5 years.

 

[sunshine1160]

I apologize for reviving this thread, but I was just wondering how the " psychiatrist" in the OP's post can even call him/herself that? I understand you can get a license after 1st year, but you need to complete residency to be called a Psychiatrist and be board eligible. Or at least I thought that was the case.

The only thing you can be called after 12 months of residency and a license is a general practitioner. Honestly, I would not want to be a GP with such little training.

 

[nitemagi]

Mixing Seroquel with Cocaine has a street name: "Rosemary's Dolly"

I apologize for reviving this thread, but I was just wondering how the " psychiatrist" in the OP's post can even call him/herself that? I understand you can get a license after 1st year, but you need to complete residency to be called a Psychiatrist and be board eligible. Or at least I thought that was the case.

It's a fair question. I'm sure if the term "psychiatrist" is a protected term or not. There's probably a lawsuit in there somewhere for misrepresentation of credentials.

 

[Rogue Penguin]

This thread is awful.