What should we do about this attending that we feel is teaching us wrong information...

[soisauce]

So I'm a second year resident and I don't claim to know everything in psychiatry but this attending has said some absurd things to us like:

1) you don't need to check labs when starting lithium 2) peritonitis is diagnosed by elevated LFTs 3) opiate withdrawal causes seizures 4) Effexor works faster than Effexor XR for depression 5) primary treatment for delirium is antipsychotics and benzodiazepines 6) patients using immature defense mechanisms don't have capacity...

There's a lot more but those are the ones I can remember at this time. We spoke with the chief resident and I think we as a group really worry about our education and the care patients are getting. I know it's hard and all, but we really don't want her teaching us.

What should we do?

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[st2205]

So I'm a second year resident and I don't claim to know everything in psychiatry but this attending has said some absurd things to us like:

1) you don't need to check labs when starting lithium 2) peritonitis is diagnosed by elevated LFTs 3) opiate withdrawal causes seizures 4) Effexor works faster than Effexor XR for depression 5) primary treatment for delirium is antipsychotics and benzodiazepines 6) patients using immature defense mechanisms don't have capacity...

There's a lot more but those are the ones I can remember at this time. We spoke with the chief resident and I think we as a group really worry about our education and the care patients are getting. I know it's hard and all, but we really don't want her teaching us.

What should we do?

Wait for someone to talk down to you and remind you you're just residents and you're training and clinical reasoning aren't complete until that magic moment where you become an attending and can diagnose schizophrenia in every cluster B person seeing shadows in the corner of their eye.

In all seriousness, though, that's probably the only thing you can do. Best of luck.

 

[nitemagi]

Your question muddles issues of 1. what to do with a bad teacher and 2. what to do with a bad supervisor.

1. Be an independent thinker/learner. People like this develop a reputation fast. Read and learn on your own, and internally question and research every bit of data this attending gives.

2. CYA. If it's dangerous, speak out. If the attending doesn't check up on the patient do what they say AND what you believe is medically necessary, informing them along the way -- "I started the haldol on the delirious patient as you instructed [documented as per Dr. A's recommendations...], and also instructed the primary team to work up for medical etiologies as I read about in X paper."

 

[novopsych]

First, precise knowledge in psychiatry is both overrated and is a unicorn. What works is what works. Psychiatry is a battlefield. You learn on the dance floor.

Second, if your attending is feeding you all this BS, they're probably setting you up. Run a background check on the person and see what you find. If the situation continues, call your local network affiliate to report the problem. The local news loves these stories.

 

[vistaril]

So I'm a second year resident and I don't claim to know everything in psychiatry but this attending has said some absurd things to us like:

1) you don't need to check labs when starting lithium 2) peritonitis is diagnosed by elevated LFTs 3) opiate withdrawal causes seizures 4) Effexor works faster than Effexor XR for depression 5) primary treatment for delirium is antipsychotics and benzodiazepines 6) patients using immature defense mechanisms don't have capacity...

There's a lot more but those are the ones I can remember at this time. We spoke with the chief resident and I think we as a group really worry about our education and the care patients are getting. I know it's hard and all, but we really don't want her teaching us.

What should we do?

I don't know about primary(a sort of meaningless word in this context) but anyone who makes enough delirium recs is going to rec antipsychotics and benzos at some point....

That said, most ICU physicians have a better handle a at delirium than psych, as do some internists

 

[johnhoedack]

Benzos? For delirium...? Now I really know you're a troll Vistaril.

 

[Beargryllz]

Present evidence

Isn't that how medicine works? Evidence-based practice or something?

 

[slappy]

That said, most ICU physicians have a better handle a at delirium than psych, as do some internists

Speak for yourself? (I suspect you are, but I still wanted to say it.)

To the OP: You can ask your attending for clarification as to why this paper you read doesn't match up with what she taught you. If that doesn't work, you should definitely bring this up with your PD. It is one of their responsibilities to make sure you are taught well, and right.

 

[erg923]

I have conducted presurgical psychological evaluations on dozens of personality disorders veterans for transplant or bariatric and never found a their "projections" to be compelling reason to question their capacity to consent to the procedure...although it had been tempting at times.

 

[michaelrack]

I don't know about primary(a sort of meaningless word in this context) but anyone who makes enough delirium recs is going to rec antipsychotics and benzos at some point....

That said, most ICU physicians have a better handle a at delirium than psych, as do some internists

I agree with Vistaril, although certainly benzo's are not first line for (known) non-ETOH/sedative withdrawal delirium

 

[notdeadyet]

I agree with Vistaril, although certainly benzo's are not first line for (known) non-ETOH/sedative withdrawal delirium

Agree with this. I would reckon about 1/3rd of the delirium consults I did was undoing delirium caused by or exacerbated by benzo use on inpatient units...

 

[VMSmith]

Benzos are far from being any kind of "primary" treatment for non-EtOH/sedative withdrawal delirium, but with that said, there are situations where using benzos in a delirious patient is the least of many evils.

 

[psychattending]

So I'm a second year resident and I don't claim to know everything in psychiatry but this attending has said some absurd things to us like:

1) you don't need to check labs when starting lithium 2) peritonitis is diagnosed by elevated LFTs 3) opiate withdrawal causes seizures 4) Effexor works faster than Effexor XR for depression 5) primary treatment for delirium is antipsychotics and benzodiazepines 6) patients using immature defense mechanisms don't have capacity...

There's a lot more but those are the ones I can remember at this time. We spoke with the chief resident and I think we as a group really worry about our education and the care patients are getting. I know it's hard and all, but we really don't want her teaching us.

What should we do?

Your program is required to be soliciting anonymous feedback from the residents. You and your colleagues can/should be providing feedback to your program in a constructive manner. You could also consider talking directly with your PD about it.

 

[splik]

Benzos? For delirium...? Now I really know you're a troll Vistaril.

although benzos are deliriogenic, they can have a role in the management of delirium bearing in mind that neuroleptics are not used to treat delirium but acute behavioral disturbances in delirium. Obviously patients with benzo- barbituarate- alcohol, baclofen- and cocaine withdrawal delirium may benefit from benzos vs. neuroleptics for delirium. those with delirium due to NMS, NMDA receptor limbic encephalitis, or acute behavioral disturbance in context of delirium in a patient with lewy body dementia, a patient with a QTc of 600 or your severe heart failure patient having runs of VTach etc, other patients who appear exquisitely sensitive to even low-potency neuroleptics in whom an IV/IM chemical restraint is needed might benefit from benzos. neurologists and ICU docs frequently use benzos for behavioral management of agitation in delirium/TME and it is not always the wrong thing to do.

 

[whopper]

Agree with psychattending.

I hope the culture of your institution would allow you to bring up the problem. I've seen some institutions where it does not. I also wish I could tell what's happening to you is surprising but it isn't. I've seen too many physicians practice as if they're making up what they're doing. Further, because doctors are a rare commodity, some programs will take low-quality doctors because it's either that or have no doctor at all or an even worse one. It's a large reason why I was willing to work in an academic institution with several good doctors for a lower salary vs working privately and be surrounded by doctors not worthy of the title.

But, at least from personal experience, I believe those malignant programs are in the minority. Definitely bring up the problems during the anonymous review at the end of the rotation. Only go further if you feel you are safe. As much as I want more crusaders in our field, there's just still too much of a malignant culture in some programs and I don't know if you're in one. I want you to be a saint, not a martyr.

My fourth year, as a chief resident, my own program went through a lot of majorly bad changes. I brought up the problems and the head of the department of one of the hospitals (the program was split between two hospitals) was telling me some of the problems were severe and way-over my head, and a lot of it was due to dysfunctional attendings.