What aspect of psychiatry has had the highest skill curve for you as a resident/attending?

[BACyeahyouknowme]

Very interesting analysis there. Unfortunately for you I finished fellowship in the last couple years

Doing a good job with medication isn't trivial but I'm also of the mindset that anyone who graduates a residency should have at least a decent knowledge of what to do or not with medications. On top of this, most of the people calling themselves "expert psychopharmacologists" aren't exactly the people on ACT teams prescribing clozapine and lithium on a daily basis...

Fellowship, or training at your local analytic institute?? Fess up!

Otherwise I’ll be forced to confront the idea that my dime store psychoanalysis could be flawed…

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[G Sheb]

You know, I had heard this idea that the pharmacology is banal and simple from a few of my program’s attendings. The ones who made these remarks were obviously trained well before me. I never thought the pharmacology was simple, and I thought mastering it involved progressive improvements in knowledge and skill, like anything else.

So I have this theory that the dismissive “pharmacology is easy” comments are coming from people who trained in an era that really valued the dynamic/analytic side of our profession, and patients getting better with “just pills” threatens the primacy of that worldview, and thus they mount these defensive responses.

Just my armchair analysis anyway.

Yeah, exactly that.

 

[ObsequiousAplomb]

You know, I had heard this idea that the pharmacology is banal and simple from a few of my program’s attendings. The ones who made these remarks were obviously trained well before me. I never thought the pharmacology was simple, and I thought mastering it involved progressive improvements in knowledge and skill, like anything else.

So I have this theory that the dismissive “pharmacology is easy” comments are coming from people who trained in an era that really valued the dynamic/analytic side of our profession, and patients getting better with “just pills” threatens the primacy of that worldview, and thus they mount these defensive responses.

Just my armchair analysis anyway.

The extremely basic psychopharmacology (that's still difficult for some providers to follow) is incredibly simple:
- patient is too sad: give them happy pills!
- patient is too sleepy: give them awake pills!
- patient is too sad and too sleepy: give them happy pills that also wake them up!
- patient is too happy: give them sad pills!
- patient is too awake: give them sleepy pills!
- patient is too anxious: give them happy pills!
- patient is too obsessive: give them more happy pills!
- patient is too distracted: give them focus pills!
- patient is too psychotic: give them antipsychotics!
- patient has a pattern of clinically significant episodes of being both too sad and too happy: give them mood stabilizers!
- patient has history of unstable mood and being too psychotic: give them mood-stablizing antipsychotics!
- patient is too psychotic and too sad: give them antipsychotics and happy pills!
- patient has an untreated medical problem that could be relevant: tell them to ask a doctor who treats that to treat it!
- 2-3 trials of the appropriate class didn't work: zap 'em!

When deciding initial treatment always give a monotherapy as above, and if that does not work then give them another monotherapy that fits the same simplistic rule. If the response is partial then add a drug from the new group that fits the new major problems. Start at the recommended starting dose. If people respond well then maintain the minimum effective dose. If they don't respond well then titrate to the maximum tolerated dose. In general consider the dose ineffective after 2 weeks and titrate higher, and consider the drug ineffective after 12 weeks at max dose tolerated.

The more advanced version still isn't all that far off from the above. It's mostly generalized rules that help with combinations of drugs for treatment-refractory cases and more detailed guidelines for doses and time-to-escalate or time -to-switch. Drug-drug interactions are frequently published with very helpful charts for studying the specific recommendations. Electronic prescribing systems auto-warn you about interactions. The ones you want to give despite the warning you look up to make sure you know what the warning means and how to respond to it.

There are fewer than 50 drugs to know. Most psychiatrists don't use more than 3 drugs in any class. Most combinations aren't any more effective than monotherapy. The exceptions are easy to read about and learn, since they tend to be published in clinical practice guidelines. FDA package inserts that every patient gets with every prescription contain more information than most people prescribing the medications know about the medications (sad but true).

It doesn't take much effort at all to follow an algorithm, all of which have generally been found to be better than or equivalent to "more thoughtful" prescribing practices. Even I admit I usually don't try two SSRIs before considering an SNRI, Remeron, Wellbutrin, or a TCA for certain patients with simple MDD. My care isn't any better or worse for having made whatever rationalization I have made to follow that action.

 

[BACyeahyouknowme]

Big ol' lump in the noggin'? Cut 'er out!
Blood tubes leakin'? Suck it out!
Brain swole up? Cut a hole and let it breathe!
Now I'm a neurosurgeon!

 

[ObsequiousAplomb]

Big ol' lump in the noggin'? Cut 'er out!
Blood tubes leakin'? Suck it out!
Brain swole up? Cut a hole and let it breathe!
Now I'm a neurosurgeon!

The difference is that neurosurgery actually benefits from extensive knowledge of neuroanatomy and learning how to use your hands.

 

[psychmd03]

You know, I had heard this idea that the pharmacology is banal and simple from a few of my program’s attendings. The ones who made these remarks were obviously trained well before me. I never thought the pharmacology was simple, and I thought mastering it involved progressive improvements in knowledge and skill, like anything else.

So I have this theory that the dismissive “pharmacology is easy” comments are coming from people who trained in an era that really valued the dynamic/analytic side of our profession, and patients getting better with “just pills” threatens the primacy of that worldview, and thus they mount these defensive responses.

Just my armchair analysis anyway.

In a way I agree but I think for specific patient populations. You have to remember the patients you are working with are very different. I see a lot of people saying gotta talk to your patient on inpatient really get to know them it's a joke to see patients in a few min. Well talk a walk down just a few patients I saw today

Patient one: "My bones all broke and I fell so hard I got a concussion I am a miracle. I regrew my bones and learned to walk and talk the last two days" Yeah you're right I could spend 30 min getting to know this patient and really talking with her. But personally, IMO that is a complete waste of time at this point in her treatment. She needs meds. But sure some might argue some good therapy might do the trick.

Patient two: "Mayonaise is the analysis I have the broker, I just skateboard to get the caucasian chicks because I run the throne" We should probably talk for another 15 min...... or maybe that was plenty of clinical to make a decision that he wont be able to give me a solid history or make a good connection and listen to therapy and actually internalize anything. I dunno your call

Patient 3: "we dont like what you are saying, we hear you talking from the shower to us....I will throw you in a garbage can" this patient randomly started stating we and was actively pacing in the room and smelled like they had not showered in the past month. No drugs on board. So yeah I guess maybe +20 of therapy ought to do the trick

So lets always keep some clinical context in mind when making broad sweeping statements or interpretations of what others say. Most of these patients I will be lucky to stabilize on one antipsychotic and one mood stabilizer.

Overall I also think psychiatrists like to think their "therapy" is so special when actually overall just developing rapport is the largest part of the benefit of therapy. I was never a therapy doctor but oddly my therapy patients in clinic did quite well. In the end, I think we aren't that special but therapy is just a fancy way to teach people how to connect with their patients. The techniques even in the literature dont move the needle much and have a large replication problem.

 

[psychmd03]

The difference is that neurosurgery actually benefits from extensive knowledge of neuroanatomy and learning how to use your hands.

Its all basic memorization in the end if we are looking to continue with such reductive thinking

 

[calvnandhobbs68]

So lets always keep some clinical context in mind when making broad sweeping statements or interpretations of what others say. Most of these patients I will be lucky to stabilize on one antipsychotic and one mood stabilizer.

Yeah this keeps coming up and maybe this isn't you...but this type of thinking on inpatient is exactly what gets everyone spun out on mood stabilizers and antipsychotics.

The argument isn't sit around and do therapy with your patients inpatient. The argument is maybe spend more than a couple minutes with a patient and you might find out they actually have autism which is why they're pacing around talking repetitive nonsense to themselves that sounds like scripts from a TV show instead of cranking up haldol until you snow them out of their minds enough to stop talking.

 

[TexasPhysician]

One of the more difficult aspects of psychiatry is identifying all of the information that the patient isn’t saying. This is one of the reasons why telepsych is clearly inferior.

Body language, tone of voice, eye contact, pupil size, avoidance, posture, etc. all tell a story that could be instrumental in providing good care. Patients lie all the time. People are conditioned to give the “right” response, not the honest response. This is also something that is hard to learn from reading a book. It requires practice, time, empathy, excellent language skills, and remaining objective while patients try to manipulate (purposefully or accidentally) the conversation.

 

[psychmd03]

Yeah this keeps coming up and maybe this isn't you...but this type of thinking on inpatient is exactly what gets everyone spun out on mood stabilizers and antipsychotics.

The argument isn't sit around and do therapy with your patients inpatient. The argument is maybe spend more than a couple minutes with a patient and you might find out they actually have autism which is why they're pacing around talking repetitive nonsense to themselves that sounds like scripts from a TV show instead of cranking up haldol until you snow them out of their minds enough to stop talking.

You dont need 10 min to figure out the patient is DD or ASD which is very apparent within 30s and getting collateral if possible (many off the streets have none). With time and experience, the pattern recognition works very quickly. And someone with ASD or DD that explosively attacked people at their group home or at home probably needs some of that awful medication you mentioned. Likely an antipsychotic, SSRI and mood stabilizer if they are doing the rounds on inpatients. That trinity works very well for that population.

 

[calvnandhobbs68]

You dont need 10 min to figure out the patient is DD or ASD which is very apparent within 30s and getting collateral if possible (many off the streets have none). With time and experience, the pattern recognition works very quickly. And someone with ASD or DD that explosively attacked people at their group home or at home probably needs some of that awful medication you mentioned. Likely an antipsychotic, SSRI and mood stabilizer if they are doing the rounds on inpatients. That trinity works very well for that population.

yeah I got it dude I worked in an actual ID/DD clinic, I'm quite familiar with the outpatient difficulties this population has.

Additionally I know you mean it sarcastically but it actually is "awful" medication especially without an actual thought process behind it (guess that's where my expert psychopharm knowledge comes in), like for instance cranking up risperdal/zyprexa/seroquel on an autistic/ID adult and now he's gone from cornerback to lineman size. So now they keep coming back inpatient again cause even their 2:1 staff has trouble handling a 275lb vs 200lb adult.
There's also some great group homes and there's plenty of ****ty group homes that just want you to snow all their residents so they don't have to monitor them or have to worry about if resident A starts banging on resident Bs door because he wants to play with him and resident B yells and punches a wall...now resident B is "aggressive, needs to go to the hospital" and sounds like you're happy to oblige pushing up his risperdal from 4mg to 6mg.

But anyway, hey if you can diagnose and figure out best treatment for someone with ID/DD/ASD by listening to them speak a couple lines, that's awesome, be sure to let your local neuropsychologists know about this because I'm sure they'd love this groundbreaking new diagnostic capability they have for their own use.

 

[hamstergang]

The extremely basic psychopharmacology (that's still difficult for some providers to follow) is incredibly simple:
...
The more advanced version still isn't all that far off from the above.

You can reduce nearly everything in life similarly, even if they can actually be complex. But I find it funny that in you attempt to reduce psychopharmacology, you ended up writing a decent length post.

There isn't an algorithm for every scenario, and nuance exists in the world. Our knowledge allows us to understand why the algorithm is what it is and how to adapt it to specific situations (and when it actually makes sense to go off script).

 

[smalltownpsych]

yeah I got it dude I worked in an actual ID/DD clinic, I'm quite familiar with the outpatient difficulties this population has.

Additionally I know you mean it sarcastically but it actually is "awful" medication especially without an actual thought process behind it (guess that's where my expert psychopharm knowledge comes in), like for instance cranking up risperdal/zyprexa/seroquel on an autistic/ID adult and now he's gone from cornerback to lineman size. So now they keep coming back inpatient again cause even their 2:1 staff has trouble handling a 275lb vs 200lb adult.
There's also some great group homes and there's plenty of ****ty group homes that just want you to snow all their residents so they don't have to monitor them or have to worry about if resident A starts banging on resident Bs door because he wants to play with him and resident B yells and punches a wall...now resident B is "aggressive, needs to go to the hospital" and sounds like you're happy to oblige pushing up his risperdal from 4mg to 6mg.

But anyway, hey if you can diagnose and figure out best treatment for someone with ID/DD/ASD by listening to them speak a couple lines, that's awesome, be sure to let your local neuropsychologists know about this because I'm sure they'd love this groundbreaking new diagnostic capability they have for their own use.

Seen these things play out quite a few times from various settings. Also, wamted to add that psychologists or others capable of well implemented effective behavioral and social interventions are rarely involved and when they are can be much more effective than any medications to help these populations. By the way, when I say social intervention what I mean spend about 30 minutes to talk to patient to help them figure out or express why they are upset and half the time that is about all we need to do.

 

[ObsequiousAplomb]

You can reduce nearly everything in life similarly, even if they can actually be complex. But I find it funny that in you attempt to reduce psychopharmacology, you ended up writing a decent length post.

There isn't an algorithm for every scenario, and nuance exists in the world. Our knowledge allows us to understand why the algorithm is what it is and how to adapt it to specific situations (and when it actually makes sense to go off script).

And that simple script is still less than a page, despite being a list of bullet points. I'm not saying that all of psychiatry or all of the clinical practice of psychopharmacology is summed up in that post, just the rudimentary basics that explain why people say learning psychopharmacology is easy. The same people who say it's easy lump every other aspect of the clinical practice of psychiatry into the psychotherapy categories, the diagnostics categories, the nosologistic categories, and the business categories. The fact that people decide bizarre things like starting drug-naive patients with 5 medications within a 5 day hospitalization is sort of my point - it doesn't make rational sense on any level, and it never will. The fact that people think an autistic person fighting with their roommate requires doses of antipsychotics, anticonvulsants, and SSRIs that are above and beyond reason just because a group home staff member is sick of dealing with group home residents is also sort of my point.

And in response to a simple reductive algorithm for neurosurgery: again, I never said it was all that was needed to be a psychiatrist. I intentionally left out the diagnosis and decision of how clinically significant the problem is because that's not part of the psychopharmacology, it's part of assessment. A similar analogy can be made with simple concepts of too much or too little blood or blood in the wrong place or non-blood fluid or the wrong solids for neurosurgery, and it would also be missing the critically important decision-making process for what extent of the problem is present and what comorbidities are in the way to make the decision.

 

[Candidate2017]

I never thought the pharmacology was simple, and I thought mastering it involved progressive improvements in knowledge and skill, like anything else.

So I have this theory that the dismissive “pharmacology is easy” comments are coming from people who trained in an era that really valued the dynamic/analytic side of our profession, and patients getting better with “just pills” threatens the primacy of that worldview, and thus they mount these defensive responses.

Psychopharmacology is relatively easy.**

And someone with ASD or DD that explosively attacked people at their group home or at home probably needs some of that awful medication you mentioned. Likely an antipsychotic, SSRI and mood stabilizer if they are doing the rounds on inpatients. That trinity works very well for that population.

Inpatient psychiatry is relatively easy.**

** By "relatively easy", I mean in regard to someone who earned a 3.5+ college GPA in a pre-med curriculum, has beaten out most med school applicants, earned a medical degree to become a physician, has at least 4 years of post-grad psychiatry training, at an established residency program, passed board certification.

And of course, psychopharm and inpatient psychiatry is relatively easy for psychiatrists, because that is the thrust of our training, rather than 4 years of fulltime psychotherapy training.

 

[Candidate2017]

You dont need 10 min to figure out the patient is DD or ASD which is very apparent within 30s and getting collateral if possible (many off the streets have none). With time and experience, the pattern recognition works very quickly. And someone with ASD or DD that explosively attacked people at their group home or at home probably needs some of that awful medication you mentioned. Likely an antipsychotic, SSRI and mood stabilizer if they are doing the rounds on inpatients. That trinity works very well for that population.

That's the inpatient formula, which boils down to treat and street. Crank up the meds, stabilize, discharge back to their doctor. Then, it's up to their doc to slowly taper down the supratherapeutic antipsychotics, taper off mood stabilizers, and educate their caretakers on behavioral interventions (exercise, socialization, sleep, anxiety, etc).

 

[G Sheb]

That's the inpatient formula, which boils down to treat and street. Crank up the meds, stabilize, discharge back to their doctor. Then, it's up to their doc to slowly taper down the supratherapeutic antipsychotics, taper off mood stabilizers, and educate their caretakers on behavioral interventions (exercise, socialization, sleep, anxiety, etc).

Eh most of the time that approach ends up hurting the patients than maybe even more if not hospitalized. It's all too common unfortunately.
Like stop their outpatient meds, do not consult their outpatient doctor or coordinate treatment for med trial history or any other important information because who has time for that, crank up a mood stabilizer and an antipsychotic, and send back a zombie for the outpatient psychiatrist to start the work all over again.
Yikes.

 

[clausewitz2]

** By "relatively easy", I mean in regard to someone who earned a 3.5+ college GPA in a pre-med curriculum, has beaten out most med school applicants, earned a medical degree to become a physician, has at least 4 years of post-grad psychiatry training, at an established residency program, passed board certification.

You don't have to be a genius to be a physician by any means, but you can't actually be stupid. It is very possible to be mostly bereft of intellectual curiosity, however, and that particular deficit won't really cause that many problems for the aforementioned non-dumdum in mastering psychopharmacology by the available practice guidelines.

 

[psychmd03]

Psychopharmacology is relatively easy.**



Inpatient psychiatry is relatively easy.**

** By "relatively easy", I mean in regard to someone who earned a 3.5+ college GPA in a pre-med curriculum, has beaten out most med school applicants, earned a medical degree to become a physician, has at least 4 years of post-grad psychiatry training, at an established residency program, passed board certification.

And of course, psychopharm and inpatient psychiatry is relatively easy for psychiatrists, because that is the thrust of our training, rather than 4 years of fulltime psychotherapy training.

You’d hope so but I am continually surprised by what I see from other docs at the hospitals I work or from docs that dc their patients that rebound in a day. So I’d fully agree relatively easy for some but many that actually are doing it don’t do it well.

 

[psychmd03]

That's the inpatient formula, which boils down to treat and street. Crank up the meds, stabilize, discharge back to their doctor. Then, it's up to their doc to slowly taper down the supratherapeutic antipsychotics, taper off mood stabilizers, and educate their caretakers on behavioral interventions (exercise, socialization, sleep, anxiety, etc).

For some but I rarely see many on supratherapuetic meds and I get to see the sickest in two hospitals that take primarily Medicaid and unfunded. And many actually sick (not the patient that wants off the streets or someone that just wants to be away from family) need a more med to break an acute episode than to maintain. You dose and evaluate based on the patients presentation and get them trending in the right direction to about 75-80% of baseline which helps make sure you don’t overshoot and transition them to an appropriate next level of care. I’ve seen patients I’ve med petitioned for 4 weeks on dual antipsychotic abs dual mood stabilizer remain manic and psychotic only to break finally at week 6 when everything was fully maximized. Treat the patient that’s in front of you. Pretty simple but seemingly not easy given what is posted on here

 

[psychmd03]

yeah I got it dude I worked in an actual ID/DD clinic, I'm quite familiar with the outpatient difficulties this population has.

Additionally I know you mean it sarcastically but it actually is "awful" medication especially without an actual thought process behind it (guess that's where my expert psychopharm knowledge comes in), like for instance cranking up risperdal/zyprexa/seroquel on an autistic/ID adult and now he's gone from cornerback to lineman size. So now they keep coming back inpatient again cause even their 2:1 staff has trouble handling a 275lb vs 200lb adult.
There's also some great group homes and there's plenty of ****ty group homes that just want you to snow all their residents so they don't have to monitor them or have to worry about if resident A starts banging on resident Bs door because he wants to play with him and resident B yells and punches a wall...now resident B is "aggressive, needs to go to the hospital" and sounds like you're happy to oblige pushing up his risperdal from 4mg to 6mg.

But anyway, hey if you can diagnose and figure out best treatment for someone with ID/DD/ASD by listening to them speak a couple lines, that's awesome, be sure to let your local neuropsychologists know about this because I'm sure they'd love this groundbreaking new diagnostic capability they have for their own use.

Well for sure I’d fully agree that’s a wild regimen that someone is just asking for some massive problems also the complete overlap in med choices make no sense. That would be someone shoot for pure sedation not functioning.

I love my DD patients that come in. Nearly 95% of the time they want to kill someone at their group home as wel as themselves. Always running away. Normally unless they are in an SODC (for only very violent DD patients) they normally aren’t on med combos any different or higher dosed than SAD patient. You gotta recognize you’ll never treat all the impulsivity.

You can be just as sarcastic but it isn’t hard to recognize a DD patient in inpatient. And if you’re taking 30 min to figure out the patient is DD on your inpatient unit I don’t know what to say to help you. These are not borderline cases. And unless they are young a new DD diagnosis on a borderline case won’t help them with services or placement since the state won’t recognize it. And honestly in terms placement will hurt then as NH at least in my state cannot take anyone with any DD/ASD diagnosis. So they end up with a shelter option or nothing if they can’t go home.

 

[Merovinge]

Well for sure I’d fully agree that’s a wild regimen that someone is just asking for some massive problems also the complete overlap in med choices make no sense. That would be someone shoot for pure sedation not functioning.

I love my DD patients that come in. Nearly 95% of the time they want to kill someone at their group home as wel as themselves. Always running away. Normally unless they are in an SODC (for only very violent DD patients) they normally aren’t on med combos any different or higher dosed than SAD patient. You gotta recognize you’ll never treat all the impulsivity.

You can be just as sarcastic but it isn’t hard to recognize a DD patient in inpatient. And if you’re taking 30 min to figure out the patient is DD on your inpatient unit I don’t know what to say to help you. These are not borderline cases. And unless they are young a new DD diagnosis on a borderline case won’t help them with services or placement since the state won’t recognize it. And honestly in terms placement will hurt then as NH at least in my state cannot take anyone with any DD/ASD diagnosis. So they end up with a shelter option or nothing if they can’t go home.

I think you two are discussing different topics. Picking up on ASD in someone who has gone through an entire lifetime of treatment without diagnosis is clearly not trivial, nor possible in a few minutes. Nor is someone with borderline intellectual functioning where that ends up being the etiology of their problems (e.g. large split in say processing speed that's in the dumps and why they can't follow along with what they need to but in the normal range of other functioning). That's a lot different than the IQ 40-55 patients you are referencing.

 

[psychmd03]

I think you two are discussing different topics. Picking up on ASD in someone who has gone through an entire lifetime of treatment without diagnosis is clearly not trivial, nor possible in a few minutes. Nor is someone with borderline intellectual functioning where that ends up being the etiology of their problems (e.g. large split in say processing speed that's in the dumps and why they can't follow along with what they need to but in the normal range of other functioning). That's a lot different than the IQ 40-55 patients you are referencing.

You’d be surprised. I have a couple frequent fliers gave no documented DD and they function at the level of a 7-9yo. A couple are in shelters and in and out of NH. A few are mostly NH but clearly shouldn’t truly be but thankfully they have some shelter. Many I’m referencing also function higher than the IQ mentioned. I have SWs that I work with that when we discuss in staffing we immediately both are on the same page. No documented DD. Semi ok functioning but likely fully complicating their life and treatment and yet from non extensive for sure not neuropsych testing level, we both independently come to the same conclusion.

I just don’t see inpatient as being that difficult to pick up on things if you have experience (much more volume than what one got as a resident unless you heavily moonlighted even then you’ll need some more fine tuning) as well as a good dependable team to help you gather details in residency you had to yourself. You train your pattern recognition on a high volume of experience taking in all the clinical you see in the chart, gather from the verbal and non verbal of the patient both talking with them and seeing them on rounds, as well as information from your nurses, techs and social workers. That’s a massive amount of info so it doesn’t take a massive interview to figure it out. There will be that patient or two every week where you walk away confused. You get all your information assimilated and it still doesn’t fit. Then you know it’s time to really dive in because clearly your priors aren’t helping you. These will also be the cases that help you dial in even further just like the ones that have bad mania or psychosis you can’t break and take 2 weeks to get down (I just had a badly psychotic older man that took 20 days to get in control but finally once it broke ir was fantastic). And then your choice of treatment can’t be way off in left field.

 

[smalltownpsych]

You’d be surprised. I have a couple frequent fliers gave no documented DD and they function at the level of a 7-9yo. A couple are in shelters and in and out of NH. A few are mostly NH but clearly shouldn’t truly be but thankfully they have some shelter. Many I’m referencing also function higher than the IQ mentioned. I have SWs that I work with that when we discuss in staffing we immediately both are on the same page. No documented DD. Semi ok functioning but likely fully complicating their life and treatment and yet from non extensive for sure not neuropsych testing level, we both independently come to the same conclusion.

I just don’t see inpatient as being that difficult to pick up on things if you have experience (much more volume than what one got as a resident unless you heavily moonlighted even then you’ll need some more fine tuning) as well as a good dependable team to help you gather details in residency you had to yourself. You train your pattern recognition on a high volume of experience taking in all the clinical you see in the chart, gather from the verbal and non verbal of the patient both talking with them and seeing them on rounds, as well as information from your nurses, techs and social workers. That’s a massive amount of info so it doesn’t take a massive interview to figure it out. There will be that patient or two every week where you walk away confused. You get all your information assimilated and it still doesn’t fit. Then you know it’s time to really dive in because clearly your priors aren’t helping you. These will also be the cases that help you dial in even further just like the ones that have bad mania or psychosis you can’t break and take 2 weeks to get down (I just had a badly psychotic older man that took 20 days to get in control but finally once it broke ir was fantastic). And then your choice of treatment can’t be way off in left field.

I never thought it was difficult either, but people misdiagnose these all the time. Especially nurses and social workers in my experience. Those two groups seem to be some of the worst at labeling based on a few details. Obnoxious patient? Obviously a borderline. Confused and/or can’t communicate well or follow simple directions, psychotic and needs more meds. You must have the fortune of working with more competent staff than I have seen in several different inpatient settings.

 

[psychmd03]

I never thought it was difficult either, but people misdiagnose these all the time. Especially nurses and social workers in my experience. Those two groups seem to be some of the worst at labeling based on a few details. Obnoxious patient? Obviously a borderline. Confused and/or can’t communicate well or follow simple directions, psychotic and needs more meds. You must have the fortune of working with more competent staff than I have seen in several different inpatient settings.

I fully agree. The team makes the difference and can truly enhance your ability to deliver good care inpatient and have confidence a good plan exists for OP. I’m fairly confident in my abilities now so I trust way less. When I first walked in as a moonlighter I assumed everyone knew more than me. It took me learning my own skills and gaining confidence to then be able to pick up on who I trust or done when they give their opinion. Some nurses are great some I completely tune out. Our intake department I will never ever trust their diagnosis. They are (imo) wrong 90% of the time. I don’t even know where they pull an idea for a diagnosis.