additional training in psych

[scharnhorst]

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Over the last few yrs I have grown quite comfortable treating psych patients and was wondering if there was a way I can get more formal training/certification in psych as a FP/FM doc?
AFAIK there are no psych fellowships for FM docs

Thanks

 

[PikminOC]

Over the last few yrs I have grown quite comfortable treating psych patients and was wondering if there was a way I can get more formal training/certification in psych as a FP/FM doc?
AFAIK there are no psych fellowships for FM docs

Thanks

Just do psych residency

 

[VA Hopeful Dr]

Outside of the Behavioral Health fellowships that you can get through FM (which don't reward you any certification or anything), there really isn't much formal education outside of a psych residency.

 

[FrustratedFamDoc]

I would just seek out additional CME. Once word gets out that you enjoy it and are half good at it, you'll have more than enough volume to keep you busy.

 

[AlbinoHawk DO]

There's the UC Irvine pseudo fellowship where you basically pay for didactics in psychiatry and only do 2 weeks at UCI. It's sort of expensive and the program admits midlevels, but it's also the closest to psychiatry training in addition to the 5 or so behavioral health programs

 

[hallowmann]

Over the last few yrs I have grown quite comfortable treating psych patients and was wondering if there was a way I can get more formal training/certification in psych as a FP/FM doc?
AFAIK there are no psych fellowships for FM docs

Thanks

I'd agree that if you are already a seasoned FM doc interested in psych, you can cater CME to its delivery in a primary care setting.

You could join AMP (Association of Medicine and Psychiatry) and see what lectures and topics they have to offer. The annual conference I believe is again virtual this year, and there are plenty of categorical docs with special interest in the other field that attend that regularly.

If you really wanted to be board certified, you could go to residency again (could probably get 1 year credit, so finish in 3 yrs), but if you're just trying to get better at the practice of psychiatry during primary care visits, then I doubt it's really worth it.

There's the UC Irvine pseudo fellowship where you basically pay for didactics in psychiatry and only do 2 weeks at UCI. It's sort of expensive and the program admits midlevels, but it's also the closest to psychiatry training in addition to the 5 or so behavioral health programs

I believe this is the website for the program you're talking about:

TNT PCP Fellowship | Department of Psychiatry & Human Behavior | University of California, Irvine

www.psychiatry.uci.edu

Not sure if it really offers anything more than other primary care behavioral fellowships.

Addiction Medicine fellowship is another 1yr option that will likely give you (some) more psych exposure, and will open up certification.

 

[heyjack70]

Short of a fellowship year, I think if you can try to get in with the local psych hospitals there is usually some type of journal club, grand rounds, or case discussion group that you could join (or even start yourself) to get more exposure to psych and maybe even some mentorship.

There's a new fellowship in Coeur d'Alene, ID (beautiful place) for FM wanting an extra year training in psych. It's true it doesn't buy you any official board eligibility or anything, but I think it is a good program. You won't come out with any experience in psychotherapy but will get much more exposure to managing more complicated psych med regimens.

 

[scharnhorst]

so how is it possible that a PA/NP who does less than a yr training in psych can act as a "psychiatrist" while a FP/MD who has seen literally five times more patients with similar issues cannot provide the same level of service ?

 

[AFMD]

I think just doing what you are comfortable with in psych, reading, and finding mentors is all you need. You already have a much better training in psychiatry that's most mental health providers, mostly being midlevels, not that they aren't amazing resources for the community. Most places have a psych shortage, and you will find plenty of patients.

If you want to get on faculty in Family Medicine there are mental health fellowships that may be useful for you. For actual practice, I think these are less useful.

There is a distance learning fellowship, but it's not that much training, and too expensive for what it is in my opinion.

Every family doctor has things they are interested in, that's what's cool about us. Usually, in a good group you can send each other stuff you enjoy doing.

 

[nexus73]

so how is it possible that a PA/NP who does less than a yr training in psych can act as a "psychiatrist" while a FP/MD who has seen literally five times more patients with similar issues cannot provide the same level of service ?

why can an family NP do ketamine, hormones, botox, vitamin infusions, medspa stuff, etc etc, and me a psychiatric physician would certainly be judged harshly for doing the same (except the ketamine I suppose)? The real world is screwed up.

 

[VA Hopeful Dr]

why can an family NP do ketamine, hormones, botox, vitamin infusions, medspa stuff, etc etc, and me a psychiatric physician would certainly be judged harshly for doing the same (except the ketamine I suppose)? The real world is screwed up.

Because we are professionals with ethics. NPs are not.

 

[michaelrack]

You as a psychiatrist, with appropriate training , could probably do the type of botox that has been shown to help depression... you could also probably do some hormonal therapy for mood disorders

 

[AFMD]

why can an family NP do ketamine, hormones, botox, vitamin infusions, medspa stuff, etc etc, and me a psychiatric physician would certainly be judged harshly for doing the same (except the ketamine I suppose)? The real world is screwed up.

This looks like an unpopular opinion, and I don't know what vitamin infusions do for anyone, but we all have the same license to practice medicine. The reality is that we are all able to do all of these things. Now, if you can get malpractice to cover, and payers to pay are other questions. And, if you have the training and experience to do them is probably the most important question of all.

 

[Drrrrrr. Celty]

so how is it possible that a PA/NP who does less than a yr training in psych can act as a "psychiatrist" while a FP/MD who has seen literally five times more patients with similar issues cannot provide the same level of service ?

Because it's easier to practice medicine not knowing that you don't know, than it is to practice it knowing it and knowing that the drugs you prescribe have risks.

That being said, I do think that medical training is convoluted, too long, and we create standards and conditions that make it inflexible.

 

[deleted1025203]

so how is it possible that a PA/NP who does less than a yr training in psych can act as a "psychiatrist" while a FP/MD who has seen literally five times more patients with similar issues cannot provide the same level of service ?

Greed and sellouts.

 

[AlbinoHawk DO]

so how is it possible that a PA/NP who does less than a yr training in psych can act as a "psychiatrist" while a FP/MD who has seen literally five times more patients with similar issues cannot provide the same level of service ?

If you want to and you're morally okay giving subpar care, go ahead and give NP+ level care in psych. Only difference will be once you **** something up and you are held to the physician standard of care. NPs get to maim people and they aren't held to equal standard because according to the law they are nurses and they can't be held to the standards of practicing medicine. This is why they practice "healthcare" according to their AANP president

 

[scharnhorst]

If you want to and you're morally okay giving subpar care, go ahead and give NP+ level care in psych. Only difference will be once you **** something up and you are held to the physician standard of care. NPs get to maim people and they aren't held to equal standard because according to the law they are nurses and they can't be held to the standards of practicing medicine. This is why they practice "healthcare" according to their AANP president

You are forgeting that a lot of areas have no psych docs like NONE
here you go to the hospital if u are suicidal or hope your pcp can manage you with some cocktail until you get in with psych MD like six months later
in that situation having a [ Psych minus one ] training might not be a bad thing afterall

 

[Splenda88]

Maybe they should create 1-yr psych fellowship for FM. People would say why not do a psych residency? The problem is that psych is no longer a residency where one needs just a pulse to get in.

 

[robellis]

Maybe they should create 1-yr psych fellowship for FM. People would say why not do a psych residency? The problem is that psych is longer a residency where one needs just a pulse to get in.

Psych is more competitive than both FM and IM so that is not correct

 

[Splenda88]

Psych is more competitive than both FM and IM so that is not correct

I know. I corrected my statement.

 

[AFMD]

Maybe they should create 1-yr psych fellowship for FM. People would say why not do a psych residency? The problem is that psych is no longer a residency where one needs just a pulse to get in.

I love credentials as much as the next person, but most of us are already doing so much psych I'm not sure what the point is. Primary care has got to be where the vast majority of outpatient psych care is done in the US.

 

[Splenda88]

I love credentials as much as the next person, but most of us are already doing so much psych I'm not sure what the point is. Primary care has got to be where the vast majority of outpatient psych care is done in the US.

Are you treating bipolar, schizophrenia etc..? If you are, that's brave. I thought psych training in FM residency was very limited based on the curriculum of my FM colleagues where I did my IM residency.

 

[AFMD]

Are you treating bipolar, schizophrenia etc..? If you are, that's brave. I thought psych training in FM residency was very limited based on the curriculum of my FM colleagues where I did my IM residency.

I really only know what it's like where I trained, and where I've worked since. I've never been able to get someone into a psychiatrist in any reasonable time frame. If there are places where this is not true, then I'd love to know where these places are!

I do treatment resistant depression, bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though. ADHD from start to finish. I have a hard time with personality disorders (who doesn't). Of course, plenty of addiction (one of the most common chronic diseases ever).

There's a lot of overlap and psych symptoms with dementia, TBI, MS, Parkinson's, somatoform, centralized pain, fibromyalgia, etc. etc. and other neuro or pain disorders for sure.

I do all outpatient. I would be completely lost with difficult inpatient or ER psych.

Edit: I really think a family or IM trained physician can do the vast majority of outpatient psych. The stuff I don't do in psych is really hard, and I wouldn't want to do. I wouldn't get a lot out of a psych residency because I can already do what I want in psych currently.

 

[robellis]

I really only know what it's like where I trained, and where I've worked since. I've never been able to get someone into a psychiatrist in any reasonable time frame. If there are places where this is not true, then I'd love to know where these places are!

I do treatment resistant depression, bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though. ADHD from start to finish. I have a hard time with personality disorders (who doesn't). Of course, plenty of addiction (one of the most common chronic diseases ever).

There's a lot of overlap and psych symptoms with dementia, TBI, MS, Parkinson's, somatoform, centralized pain, fibromyalgia, etc. etc. and other neuro or pain disorders for sure.

I do all outpatient. I would be completely lost with difficult inpatient or ER psych.

Edit: I really think a family or IM trained physician can do the vast majority of outpatient psych. The stuff I don't do in psych is really hard, and I wouldn't want to do. I wouldn't get a lot out of a psych residency because I can already do what I want in psych currently.

That’s very impressive, how long are your follow up appointments? Are they 30minutes? Most of my PCP colleagues just don’t have the time to handle psych patients

 

[Splenda88]

There's a lot of overlap and psych symptoms with dementia, TBI, MS, Parkinson's, somatoform, centralized pain, fibromyalgia, etc. etc. and other neuro or pain disorders for sure.

I do all outpatient. I would be completely lost with difficult inpatient or ER psych.

Edit: I really think a family or IM trained physician can do the vast majority of outpatient psych. The stuff I don't do in psych is really hard, and I wouldn't want to do. I wouldn't get a lot out of a psych residency because I can already do what I want in psych currently.

I am not sure about that. I am IM trained and I dont know anyone in my graduating class who would be comfortable treating 'ADHD, resistant depression, very bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though.' I guess my training was very subpar psychiatric-wise.

It's amazing you are able to do all that.

 

[robellis]

I am not sure about that. I am IM trained and I dont know anyone in my graduating class who would be comfortable treating 'ADHD, resistant depression, very bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though.' I guess my training was very subpar psychiatric-wise.

It's amazing you are able to do all that.

He has likely been practicing for many years as an attending and just learning as he goes I’m assuming..it’s definetly not normal for anyone outside of psychiatrists to come out of residency prepared to handle that or even close to it

 

[avatarftw]

I am not sure about that. I am IM trained and I dont know anyone in my graduating class who would be comfortable treating 'ADHD, resistant depression, very bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though.' I guess my training was very subpar psychiatric-wise.

It's amazing you are able to do all that.

I'm FM and I think that another question to be asked is if you really are able to treat some of the more complex psychiatric cases in a 20 minute visit.

Our program had a fair amount of psych, likely more than the average residency program. That being said, I prefer simple depression and anxiety cases and not bipolar, ADHD, PTSD, etc. Adult ADHD, in particular, can present with PTSD, suicidality, bipolar, and is fairly difficult to treat.

If you have 40 min a visit then it's possible but some of the more complex cases really should be managed by psychiatry

 

[AFMD]

That’s very impressive, how long are your follow up appointments? Are they 30minutes? Most of my PCP colleagues just don’t have the time to handle psych patients

I work at the VA which explains a lot of how I practice.

I have 30 minute appointments for follow-ups and 60 minutes for new patients. I can make some of my difficult follow ups 60 minutes as well.

I work with an RN and two pharmacists who also do some follow up.

Our specialists are not paid on production, and will do anything to walk you through how to do something instead of taking on a patient.

The VA population is a lot of pain, addiction, and psych.

I am not sure about that. I am IM trained and I dont know anyone in my graduating class who would be comfortable treating 'ADHD, resistant depression, very bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though.' I guess my training was very subpar psychiatric-wise.

It's amazing you are able to do all that.

When I got out of residency my first job fell through, and I actually worked at an addiction/psych practice where I did a couple rotations as a resident for almost a year before going full time at the VA. Kind of a unique experience, almost like a fellowship for me. The medical director was a psychiatrist and was an amazing mentor.

He has likely been practicing for many years as an attending and just learning as he goes I’m assuming..it’s definetly not normal for anyone outside of psychiatrists to come out of residency prepared to handle that or even close to it

I'm a few years out of training, but have had a few unique situations as above.

What's really cool about family medicine is you can do what you want, and that's pretty much what I do.

I haven't seen any pediatric patients in years, and there are other weaknesses I have as well. You can't do it all.

I'm FM and I think that another question to be asked is if you really are able to treat some of the more complex psychiatric cases in a 20 minute visit.

Our program had a fair amount of psych, likely more than the average residency program. That being said, I prefer simple depression and anxiety cases and not bipolar, ADHD, PTSD, etc. Adult ADHD, in particular, can present with PTSD, suicidality, bipolar, and is fairly difficult to treat.

If you have 40 min a visit then it's possible but some of the more complex cases really should be managed by psychiatry

I really agree, and I refer when I need to, or if it's requested by the patient.

 

[InternistDO]

I am not sure about that. I am IM trained and I dont know anyone in my graduating class who would be comfortable treating 'ADHD, resistant depression, very bad anxiety, PTSD, OCD, and bipolar all day every day. Some stable schizophrenia/schizophreniform, not much though.' I guess my training was very subpar psychiatric-wise.

It's amazing you are able to do all that.

We treat most of this (not ADHD or OCD) in my IM resident clinic, though more out of necessity since getting our patients to see psych is borderline impossible.

I don't think we get enough formal training on it though, so I've been doing some learning on the side.

 

[robellis]

We treat most of this (not ADHD or OCD) in my IM resident clinic, though more out of necessity since getting our patients to see psych is borderline impossible.

I don't think we get enough formal training on it though, so I've been doing some learning on the side.

How long is the wait to see a psychiatrist? Where are you located?

 

[InternistDO]

How long is the wait to see a psychiatrist? Where are you located?

3-6 months usually, and there's no guarantee you're getting an actual doctor vs an NP.

Location is a giant city in the northeast, but in an extremely poor area of it so the issue is all insurance/access.

 

[FrustratedFamDoc]

I know I'm opening a can of worms, and perhaps I was bombarded with psych in residency so I received better training than I realized, but I really don't see the big deal with treating bread and butter usual stuff, ie Anxiety, depression, bipolar 1/2, ADHD, in FM/IM clinic. I've been in this gig for 12 years now so I feel as if my technique is pretty time tested. I've had to send a few of my more challenging cases to psych (typically bipolar 1 and axis 2 patients). Schizophrenia is an automatic psych referal. Prior hospitalization is an automatic psych referal. My patients typically feel much better within 2-3 months of initiating treatment and I very, very rarely use benzos and keep my polypharmacy very limited. I watch weight gain carefully. I don't do zombies.

Similar to derm, most roads lead to the same treatment modality. Establish boundaries. Here's what I can do for you, here's what you can do for you. Are we not achieving what we need to because of me, you, or both?

Not being confrontational at all but please tell me where I'm going wrong or what I'm missing.

 

[robellis]

I know I'm opening a can of worms, and perhaps I was bombarded with psych in residency so I received better training than I realized, but I really don't see the big deal with treating bread and butter usual stuff, ie Anxiety, depression, bipolar 1/2, ADHD, in FM/IM clinic. I've been in this gig for 12 years now so I feel as if my technique is pretty time tested. I've had to send a few of my more challenging cases to psych (typically bipolar 1 and axis 2 patients). Schizophrenia is an automatic psych referal. Prior hospitalization is an automatic psych referal. My patients typically feel much better within 2-3 months of initiating treatment and I very, very rarely use benzos and keep my polypharmacy very limited. I watch weight gain carefully. I don't do zombies.

Similar to derm, most roads lead to the same treatment modality. Establish boundaries. Here's what I can do for you, here's what you can do for you. Are we not achieving what we need to because of me, you, or both?

Not being confrontational at all but please tell me where I'm going wrong or what I'm missing.

I don’t think you’re going wrong anywhere I mean if someone can’t get in to see a psychiatrist there’s not really many other options you have other than to refer them and treat what you can in the meantime, it’s not an easy situation but you do what you can for your patients