NontradCA

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As Im finishing up my last month of inpatient medicine I thought of a real positive quality of life and overall educational advantage of psych over most other residencies: The absence of archaic hierarchy of medicine. At most psychiatry residency programs there is not such thing as “senior” resident at a functional level.

Most of the time you are working 1-1 with an attending, of which whom there is no trickle down abuse. There is no “nows my turn to bully”. When there is interaction between residents it’s usually professional at worst, friendly at best and the interactions are not to delegate tasks.

What do you guys think? I think this is possibly the best benefit of psych residency.
 
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I actually like having upper level residents. I think it facilitates more independence on units and allows us, as interns, to ask stupid questions or learn without being told exactly what to do by attendings. It also takes a way an opportunity we would get as upper levels to supervise ppl below us before we become attendings and it can go a long way toward interclass cohesion in a residency program... Though I realize my opinion on this lay differ from other ppl. I would like a mix of both options personally...

Though it seems like you've had bad interactions with upper level?
 

Armadillos

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I think your right for the wrong reasons. It is great in psych that most upper levels are able to avoid the special hell that is acute stay inpatient psychiatry and instead can spend their time doing more meaningful work. But if upper levels did a lot of inpatient, I expect they would be nice because most psychiatrists in my hospital system are easy to get along with.
 
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NontradCA

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In theory having upper levels to supervise and teach is good but the attending is almost always going to be a better teacher. There are a lot of fragile egos in medicine and it shows in leadership. It’s just by the time doctors become attendings they have learned to care about other things besides medicine. Which, if you have plenty of in residency, you won’t be missing much interaction between residents. That being said I’ve made great friends. I have had some negative interactions with some upper levels but not so much. I just don’t believe senior residents have the maturity or experience to be leaders. You get next to zero experience in leadership in residency. And to Spliks point that is why the hierarchy you described is much different.
 

clausewitz2

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I think your right for the wrong reasons. It is great in psych that most upper levels are able to avoid the special hell that is acute stay inpatient psychiatry and instead can spend their time doing more meaningful work. But if upper levels did a lot of inpatient, I expect they would be nice because most psychiatrists in my hospital system are easy to get along with.
I am always slightly gobsmacked when fellow residents who I really respect and think are sharp tell me what they really want to do is acute inpatient work.
 
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In theory having upper levels to supervise and teach is good but the attending is almost always going to be a better teacher. There are a lot of fragile egos in medicine and it shows in leadership. It’s just by the time doctors become attendings they have learned to care about other things besides medicine. Which, if you have plenty of in residency, you won’t be missing much interaction between residents. That being said I’ve made great friends. I have had some negative interactions with some upper levels but not so much. I just don’t believe senior residents have the maturity or experience to be leaders. You get next to zero experience in leadership in residency. And to Spliks point that is why the hierarchy you described is much different.
It's true that attendings should theoretically be able to teach better, but I think there's a great deal of learning to be had by independence of making a decision and enacting it. I don't really expect my upper levels to teach me everything under the sun, so much as help me not mess up patient care or input orders incorrectly. Once we create a plan, the learning comes from tinkering the plan when discussing it with the attending.

I also think that if residents never have an opportunity to learn to teach or lead, then they don't magically become great teachers after finishing. You don't really rectify the problem of residents being ineffective leaders by not encouraging them to lead and ignoring that part of their development. Plus having attendings always present can be a safety net that covers up lack of reading and self-motivation to learn and impedes confidence in our own decision making down the line.

Though @Armadillos is right. I say this based on my off-service experiences, but I would detest having to come back to the inpatient side after PGY2.
 

Mad Jack

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In theory having upper levels to supervise and teach is good but the attending is almost always going to be a better teacher. There are a lot of fragile egos in medicine and it shows in leadership. It’s just by the time doctors become attendings they have learned to care about other things besides medicine. Which, if you have plenty of in residency, you won’t be missing much interaction between residents. That being said I’ve made great friends. I have had some negative interactions with some upper levels but not so much. I just don’t believe senior residents have the maturity or experience to be leaders. You get next to zero experience in leadership in residency. And to Spliks point that is why the hierarchy you described is much different.
Disagree with the leadership bit. We are very involved in leading teams, developing our clinics, and working with upper level administration with regard to improvements for both the inpatient and outpatient services. I also function basically independent of my attending for most of the day, and during that time am making key decisions and functioning as a leader with my nurses and ancillary staff who look to me for orders and guidance. I also generally have medical students which help me cultivate the teaching aspects that are required of a good physician leader, as cultivating the skills of trainees and peers is critical to good leadership
 
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Mass Effect

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In theory having upper levels to supervise and teach is good but the attending is almost always going to be a better teacher. There are a lot of fragile egos in medicine and it shows in leadership. It’s just by the time doctors become attendings they have learned to care about other things besides medicine. Which, if you have plenty of in residency, you won’t be missing much interaction between residents. That being said I’ve made great friends. I have had some negative interactions with some upper levels but not so much. I just don’t believe senior residents have the maturity or experience to be leaders. You get next to zero experience in leadership in residency. And to Spliks point that is why the hierarchy you described is much different.
I think as you progress past intern year, you will realize that it isn't as black and white as you think. There are some attendings who have zero leadership experience and PGY 2s who have tons. There are some attendings who don't know how to teach the basics of bipolar disorder and PGY 3s who can teach you all the rarely known nuances of organic brain diseases and neuropsychiatric ailments. Your thinking is very one-sided and you're making a ton of assumptions just based on years in the field. You'll find there are attendings of every stripe -- those who are actually good and those who are just collecting a paycheck. Same with residents.
 

Coupd'Cat

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In theory having upper levels to supervise and teach is good but the attending is almost always going to be a better teacher. There are a lot of fragile egos in medicine and it shows in leadership. It’s just by the time doctors become attendings they have learned to care about other things besides medicine. Which, if you have plenty of in residency, you won’t be missing much interaction between residents. That being said I’ve made great friends. I have had some negative interactions with some upper levels but not so much. I just don’t believe senior residents have the maturity or experience to be leaders. You get next to zero experience in leadership in residency. And to Spliks point that is why the hierarchy you described is much different.
I think it depends. Even if an attending is around doesn't mean they want to or can teach effectively. I had a rotation with three attendings supervising two interns. We saw them probably a grand total of half an hour each daily before they scuttled off to their offices or afternoon clinics. Communication was mainly through texts. It was hierarchy without the camaraderie or inter-class cohesion.

I actually like having upper level residents. I think it facilitates more independence on units and allows us, as interns, to ask stupid questions or learn without being told exactly what to do by attendings. It also takes a way an opportunity we would get as upper levels to supervise ppl below us before we become attendings and it can go a long way toward interclass cohesion in a residency program... Though I realize my opinion on this lay differ from other ppl. I would like a mix of both options personally...
On the rotations we've had senior psychiatry residents (PGY4s on education rotations or chiefs), they've helped answer questions regarding logistics and workflow. This is especially the case when we have attending who trained in other institutions. It's also been fun to learn from the PGY2s and psych fellows I consult while on off-service rotations.

But I agree--even when we have senior residents on psych, I view them as in more as a supportive role (they're pulling their weight/training us/being role models) than managerial (just someone else giving orders). They organize didactics, work on their own things, and do supervision.

edited for clarity.
 
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Mad Jack

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I think it depends. Even if an attending is around doesn't mean they want to or can teach effectively. I had a rotation with three attendings supervising two interns. We saw them probably a grand total of half an hour each daily before they scuttled off to their offices or afternoon clinics. Communication was mainly through texts. It was hierarchy without the camaraderie or inter-class cohesion.

On the rotations we've had senior psychiatry residents (PGY4s on education rotations or chiefs), they've helped answer questions regarding logistics and workflow. This is especially the case when we have attending who trained in other institutions. It's also been fun to learn from the PGY2s and psych fellows I consult while on off-service rotations.

But I agree--even when we have senior residents on psych, I view them as in more as a supportive role than managerial. They organize didactics, work on their own things, and do supervision.
Leadership doesn't mean management. Leadership is when you give an example that other people find worth following, and when you can build something up to better than it was when you arrived. ****ty IM seniors that tell their interns what to do aren't leaders. The people you've come across that you seek to emulate, that have given you something to aspire to- that is leadership
 

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The hierarchy of IM was the reason I opted for psychiatry as my final decision, I agree the lifestyle-ness of psych is amazing. But, it's not everyone's cup of tea
 
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There’s a big difference between management and leadership. And I stand by my statement that there is little to no leadership training in residency, hence comments above about attendings not being leaders and my earlier statements about attendings failure of leadership not effecting you because of where they are in life.
 
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Aren't you an intern? Pretty big assumption there.
Its not an assumption. It’s an observation. Just to go on with your line of thinking- I’ve received zero yet I will be a senior soon. Not that it matters a la my original point. But my medicine intern friends will be leading interns in a couple months here...and I know they’re not trained in leadership skills. But I digress. This could just be my n=1 as I’ve never been in residency anywhere else.
 

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Agreed OP!

At our program ever since I was an intern, our seniors have had the tradition of protecting us from pathological attendings and letting us go home early at the first possible moment. Our culture has continued in a way that we strive to do the same! :)
 
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hallowmann

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Its not an assumption. It’s an observation. Just to go on with your line of thinking- I’ve received zero yet I will be a senior soon. Not that it matters a la my original point. But my medicine intern friends will be leading interns in a couple months here...and I know they’re not trained in leadership skills. But I digress. This could just be my n=1 as I’ve never been in residency anywhere else.
Yeah, this really varies by residency. Its certainly not a given that you will have leadership training in residency, but a program with a good culture will also be a program that teaches you to be a good or at least OK leader, simply by virtue of example, guidance and the support of seniors.
 
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dizzave

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I would agree that the degree of leadership varies from program to program and in some cases even year to year within the same program. The level of teaching from the attendings can also vary depending on faculty turnover or even the same faculty with a change in their job/duties.

I've also seen major changes in leadership year to year based on the chief resident and the 4th year class through the different years of my training. In my program the primary time for resident to resident teaching (vs resident to med student teaching) and resident leadership is during evening and weekend call when there is an intern and an upper level on together - especially early in the year when the pair is hip to hip and at times interns are essentially shadowing while getting used to the computer systems and work flow. Checked out/lazy/****ty upper levels can propagate bad habits and poor leadership while engaged/thoughtful/teaching upper levels can really enhance the learning experience for interns.

All that aside however I think the real overlooked benefit of psychiatry residency is all the time off compared to other specialties. As an intern I had 14 single day 12-hour weekend shifts, 10 as a PGY2, 8 as a PGY3, and 4 as a PGY4 (stacked early to get them out of the way and to get more experienced residents with the interns the first few months). Some programs have even less call than that. Some even have none as a PGY4! How many other specialties essentially guarantee you 3 or 4 or 5 golden weekends A MONTH?! I was annoyed when I didn't have the whole damn weekend off. Taking a 9 day vacation? Only use 5 days of total vacation days. Holiday Monday or Friday? Almost an automatic 3 day weekend - unless unlucky and working a 12-hour shift. Thanksgiving? 4 day weekend unless taking a holiday shift or unlucky and getting a shift that weekend. It's a lot easier to not suffer "burnout" when you know you won't be working more than 6 days straight and that multiple times a month you can stay away from the hospital for two days and three nights consecutively.
 

Stagg737

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Its not an assumption. It’s an observation. Just to go on with your line of thinking- I’ve received zero yet I will be a senior soon. Not that it matters a la my original point. But my medicine intern friends will be leading interns in a couple months here...and I know they’re not trained in leadership skills. But I digress. This could just be my n=1 as I’ve never been in residency anywhere else.
Sounds like an n=1 statement, as my residency seems to do just the opposite.
 

Stagg737

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It is great in psych that most upper levels are able to avoid the special hell that is acute stay inpatient psychiatry and instead can spend their time doing more meaningful work.
I am always slightly gobsmacked when fellow residents who I really respect and think are sharp tell me what they really want to do is acute inpatient work.
Why the hate for acute inpatient? And what would be considered "more meaningful work"?
 
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Armadillos

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Why the hate for acute inpatient? And what would be considered "more meaningful work"?
For me personally pretty much anything would be more meaningful than acute inpatient or ER psych, because for me personally developing a relationship over time is a hallmark of psychiatry.

Also at many hospitals it’s a horrible situation where the patients who do need to be there are getting booted out by insurance/hospital admins and then the patients who don’t need to be there are refusing to leave and security is nearly dragging them off unit.

Also completely anecdotally and small sample size, on average acute short stay inpatient psychiatrists seem more concerned with RVUs/“efficiency”/etc than actually being invested in their patients as people, so I just don’t really like that environment.

It is fun to stabilize floridly manic or psychotic folks, but not particularly intellectually interesting for me at this point given how easy the decision making generally is
 
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Yeah, this really varies by residency. Its certainly not a given that you will have leadership training in residency, but a program with a good culture will also be a program that teaches you to be a good or at least OK leader, simply by virtue of example, guidance and the support of seniors.
Agreed. The varying culture of malignantvs supportive residency reflects the dichotomy of leadership styles from one of encouragement and guidance vs that of punishment and heirarchy. This includes actual support and wellness vs exhaustive burnout and extensive politics. This all trickles down to residents either good or bad depending on where they train.
 

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For me personally pretty much anything would be more meaningful than acute inpatient or ER psych, because for me personally developing a relationship over time is a hallmark of psychiatry.

Also at many hospitals it’s a horrible situation where the patients who do need to be there are getting booted out by insurance/hospital admins and then the patients who don’t need to be there are refusing to leave and security is nearly dragging them off unit.

Also completely anecdotally and small sample size, on average acute short stay inpatient psychiatrists seem more concerned with RVUs/“efficiency”/etc than actually being invested in their patients as people, so I just don’t really like that environment.

It is fun to stabilize floridly manic or psychotic folks, but not particularly intellectually interesting for me at this point given how easy the decision making generally is
You've eloquently described my lack of interest in inpatient psych, outside my general dislike of working inside a hospital. Completely agree.
 
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For me personally pretty much anything would be more meaningful than acute inpatient or ER psych, because for me personally developing a relationship over time is a hallmark of psychiatry.

Also at many hospitals it’s a horrible situation where the patients who do need to be there are getting booted out by insurance/hospital admins and then the patients who don’t need to be there are refusing to leave and security is nearly dragging them off unit.

Also completely anecdotally and small sample size, on average acute short stay inpatient psychiatrists seem more concerned with RVUs/“efficiency”/etc than actually being invested in their patients as people, so I just don’t really like that environment.

It is fun to stabilize floridly manic or psychotic folks, but not particularly intellectually interesting for me at this point given how easy the decision making generally is
You don’t think clinics are going to be focused on wRVUs and efficiency? About keeping a panel of insured, functional patients rather than the people that could most benefit?

I’m just a Hospitalist who had mostly good upper levels and staff, but I’m a lot less naive than I used to be. Dollar signs run the world.
 

clausewitz2

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You don’t think clinics are going to be focused on wRVUs and efficiency? About keeping a panel of insured, functional patients rather than the people that could most benefit?

I’m just a Hospitalist who had mostly good upper levels and staff, but I’m a lot less naive than I used to be. Dollar signs run the world.
Even from a strictly mercenary perspective, you are going to act differently and be more invested in building a relationship with those insured, functional patients because as an outpatient doc you have to keep them coming back of their own free will. This is rarely a problem for inpatient docs in psychiatry.
 
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Stagg737

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For me personally pretty much anything would be more meaningful than acute inpatient or ER psych, because for me personally developing a relationship over time is a hallmark of psychiatry.
I can understand that sentiment. However, the acute stabilization of mania and psychosis, specifically first episodes, is the thing that really got me hooked into psychiatry. That's not something you're going to see on an outpatient basis, and if you do you're not going to be managing it as you'll be admitting to an inpatient unit. Plus a lot of psychiatrists work in both inpt and outpt settings, so the opportunity to manage all aspects of patient care is an option (another thing which drew me to psych).

Also at many hospitals it’s a horrible situation where the patients who do need to be there are getting booted out by insurance/hospital admins and then the patients who don’t need to be there are refusing to leave and security is nearly dragging them off unit.
I've certainly seen this, but I've also rotated/worked in places where the teams will fight tooth and nail to get extensions to patient's stays covered by insurance. I think this is more of a cultural issue with administration than a true characterization of inpatient psychiatry, and it's one that can be fought if you document well and give proper justifications for the treatment plan.

Also completely anecdotally and small sample size, on average acute short stay inpatient psychiatrists seem more concerned with RVUs/“efficiency”/etc than actually being invested in their patients as people, so I just don’t really like that environment.
This one I'll disagree with. I actually think the outpatient docs are far more concerned with billing codes and RVUs than inpatient docs. On the inpatient unit it's pretty easy to code properly for acute mania/psychosis/suicidality/etc. On the flip side, I've seen a lot more comments come out of discussions on the outpatient side in regards to proper billing practices and RVUs. Additionally, I think the outpt docs typically receive reimbursement through models which required them to be conscious of the codes their using and their RVUs where as most inpatient docs are going to either be getting a flat salary or a base + RVU based bonus.

Use this site as an example. We see threads about coding and proper documentation all the time. Every one that I can think of is a question coming from the outpatient setting, and I don't think I've ever seen a thread in the psych forums asking about coding on the inpatient side. If inpatient docs were so concerned with the RVUs and billing, I feel like we'd see a lot more questions regarding that here (and I would in real life) than we do.

I can maybe buy the part about being invested in the patient, as outpt docs are developing long-term relationships, but again, I feel like the units which are more focused on churn control than patient care are typically a result of administrative culture and not the actual desires of the treating physician (and can be fought as stated above if one were inclined to do so)

It is fun to stabilize floridly manic or psychotic folks, but not particularly intellectually interesting for me at this point given how easy the decision making generally is
Mostly fair. However, most units will see more than just manic and psychotic patients. There's the depressed patients, substance abuse, personality disorders, along with all the other major/common co-morbidities like OCD or ADHD. I think what you're expressing is the tendency to only focus or focus heavily on the chief complaint during inpatient stays with the tendency to not address many of the comorbidities unless they're an obvious part of the reason for admission. I had an attending on a recent rotation who was extremely thorough with her psych ROS and really stressed the importance of addressing every aspect of care when possible so there's a general plan/direction in place for when the patient is seen for outpt follow-up. I think identifying unaddressed co-morbidities and underlying conditions which have been previously missed is a big part of inpatient care and can be just as intellectually stimulating as care in the outpt setting.

The major difference I see is that if you really want to incorporate psychotherapy as a major component of your treatments, it would be much harder to do on the inpatient unit beyond supportive therapy and maybe some initial psychodynamic therapy. However, I would argue that just performing pyschotherapy doesn't necessarily make treatment more intellectually interesting.
 

clausewitz2

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I can understand that sentiment. However, the acute stabilization of mania and psychosis, specifically first episodes, is the thing that really got me hooked into psychiatry. That's not something you're going to see on an outpatient basis, and if you do you're not going to be managing it as you'll be admitting to an inpatient unit. Plus a lot of psychiatrists work in both inpt and outpt settings, so the opportunity to manage all aspects of patient care is an option (another thing which drew me to psych).



I've certainly seen this, but I've also rotated/worked in places where the teams will fight tooth and nail to get extensions to patient's stays covered by insurance. I think this is more of a cultural issue with administration than a true characterization of inpatient psychiatry, and it's one that can be fought if you document well and give proper justifications for the treatment plan.



This one I'll disagree with. I actually think the outpatient docs are far more concerned with billing codes and RVUs than inpatient docs. On the inpatient unit it's pretty easy to code properly for acute mania/psychosis/suicidality/etc. On the flip side, I've seen a lot more comments come out of discussions on the outpatient side in regards to proper billing practices and RVUs. Additionally, I think the outpt docs typically receive reimbursement through models which required them to be conscious of the codes their using and their RVUs where as most inpatient docs are going to either be getting a flat salary or a base + RVU based bonus.

Use this site as an example. We see threads about coding and proper documentation all the time. Every one that I can think of is a question coming from the outpatient setting, and I don't think I've ever seen a thread in the psych forums asking about coding on the inpatient side. If inpatient docs were so concerned with the RVUs and billing, I feel like we'd see a lot more questions regarding that here (and I would in real life) than we do.

I can maybe buy the part about being invested in the patient, as outpt docs are developing long-term relationships, but again, I feel like the units which are more focused on churn control than patient care are typically a result of administrative culture and not the actual desires of the treating physician (and can be fought as stated above if one were inclined to do so)



Mostly fair. However, most units will see more than just manic and psychotic patients. There's the depressed patients, substance abuse, personality disorders, along with all the other major/common co-morbidities like OCD or ADHD. I think what you're expressing is the tendency to only focus or focus heavily on the chief complaint during inpatient stays with the tendency to not address many of the comorbidities unless they're an obvious part of the reason for admission. I had an attending on a recent rotation who was extremely thorough with her psych ROS and really stressed the importance of addressing every aspect of care when possible so there's a general plan/direction in place for when the patient is seen for outpt follow-up. I think identifying unaddressed co-morbidities and underlying conditions which have been previously missed is a big part of inpatient care and can be just as intellectually stimulating as care in the outpt setting.

The major difference I see is that if you really want to incorporate psychotherapy as a major component of your treatments, it would be much harder to do on the inpatient unit beyond supportive therapy and maybe some initial psychodynamic therapy. However, I would argue that just performing pyschotherapy doesn't necessarily make treatment more intellectually interesting.
Coming to conclusions about what the work is like based on the frequency of threads on an Internet forum is not a good idea.

I disagree strongly with the contention that you are not going to see mania or psychosis, especially first episodes, on an outpatient basis. I also disagree strongly with the idea that it will inevitably lead to hospitalization. The first episode population in particular is much less likely to agree to voluntary hospitalization and in many states if there is no evidence for acute lethality you will be dealing with this on an outpatient basis or not at all. Hell, we occasionally manage catatonia on an outpatient basis - not an everyday occurrence by any means but in the right circumstances it is workable.

While the very acute mania or psychosis stabilization that has been mentioned is probably a legitimate function of inpatient units, I don't think hospitalization on the model currently prevalent in the United States (admissions <7 days) is helpful for the vast majority of people who are admitted. I just don't think most psychiatric problems are meaningfully addressable in this period of time, and outside of highly specialized and/or private centers, most places have a sad pretense of a therapeutic milieu. We know that inpatient hospitalization doesn't actually seem to impact suicide rates very much and indeed people are at higher risk for attempting suicide after discharge even accounting for pre-hospitalization risk factors. Real change takes time and you cannot do that in less than a week. In the few places left where there might be quite lengthy admissions (and it is more of a highly secured residential program) I am sure you can do quite a lot, but this is not at all modal.

Putting down ICD-10 codes and starting a medication to match is not very challenging. The tricky part for most patients comes in assessing change over time, longitudinal monitoring, and the subtleties of when and how to make adjustments or change course.

You talk about addressing personality disorders as part of your inpatient treatment - how exactly are you doing this during an acute inpatient admission?
 

Stagg737

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I disagree strongly with the contention that you are not going to see mania or psychosis, especially first episodes, on an outpatient basis. I also disagree strongly with the idea that it will inevitably lead to hospitalization. The first episode population in particular is much less likely to agree to voluntary hospitalization and in many states if there is no evidence for acute lethality you will be dealing with this on an outpatient basis or not at all.
The bolded is assuming you're in a clinic that takes walk-ins or has the ability to squeeze patients in due to no-shows or cancellations. I'm sure there's plenty of places like this, but I have not experienced any of them yet (have rotated through 4-5 outpatient settings so far). Additionally, if a patient is in a full manic state (which is what I was referring to, not hypomania or early signs) I think it would be somewhat irresponsible to try and manage this in an outpatient setting without significant social support. I'd honestly question the validity of a manic diagnosis in someone whose "active mania" is being managed decently in an outpatient setting.

While the very acute mania or psychosis stabilization that has been mentioned is probably a legitimate function of inpatient units, I don't think hospitalization on the model currently prevalent in the United States (admissions <7 days) is helpful for the vast majority of people who are admitted. I just don't think most psychiatric problems are meaningfully addressable in this period of time, and outside of highly specialized and/or private centers, most places have a sad pretense of a therapeutic milieu. We know that inpatient hospitalization doesn't actually seem to impact suicide rates very much and indeed people are at higher risk for attempting suicide after discharge even accounting for pre-hospitalization risk factors. Real change takes time and you cannot do that in less than a week. In the few places left where there might be quite lengthy admissions (and it is more of a highly secured residential program) I am sure you can do quite a lot, but this is not at all modal.
I don't disagree with the majority of this, especially your points that true stabilization and improvements take time. Maybe I've been lucky in the sense that every inpatient unit I've worked on or in close proximity to (which is now 5) typically keeps patients who are admitted in full mania for more than 7 days. The rare instances where they left before were typically because the patient became non-compliant with their very effective meds for some reason and showed immediate improvement when restarted on them. Even then, most of those patients were staying about 7 days. So again, I'd question either the diagnosis or the treatment plan of someone successfully treating and stabilizing full-blown manic episodes in 3-4 days on a regular basis. However, I do think you can achieve some pretty good outcomes in terms of stabilization in a 10-14 day time frame, which is what I've typically seen when working with patients coming in with legitimate mania.

Putting down ICD-10 codes and starting a medication to match is not very challenging. The tricky part for most patients comes in assessing change over time, longitudinal monitoring, and the subtleties of when and how to make adjustments or change course.
Again, I don't disagree but I think this is an oversimplification of what good inpatient care looks like. Addressing co-morbidities, working with other teams (psychology, SW, etc) to provide a broader and more comprehensive social plan, and coming up with treatment plans which will guide the outpatient physician (as opposed to just stabilized and d/c which I realize is probably very common) are all parts of that inpatient care. Ideally, I'd like to see more people being able to participate in PHP or IOP programs to provide some continuity of care and more subacute treatment/monitoring before getting in to the outpatient docs, but I don't have the experience with these types of programs to really know how significant of a difference that would make compared to immediate and frequent outpatient follow up.

You talk about addressing personality disorders as part of your inpatient treatment - how exactly are you doing this during an acute inpatient admission?
Well let's start with the obvious point of just identifying them. There's more time to do this on an inpatient unit and you have staff who can actually see behaviors and tendencies in person as opposed to relying on the patient interview in a limited time period, hopefully along with some collateral if they show up to the appointment with someone else. Again, co-morbidities can be addressed and if there is a psychology team available you can get some input as to whether laying some groundwork for ongoing therapy after d/c is possible as opposed to having to refer out (unless you have an in-house psychiatrist or plan on doing the therapy yourself). You also typically have more time on the inpatient side to gather collateral from family or friends and pin down a diagnosis better from what I've seen so far.

I realize that in terms of actual treatment, there's not going to be much that one would actually do in most instances. I do think it can give more insight into the likelihood of some co-morbid conditions or underlying thought processes (or lack thereof) in those individuals though, which I think is far more difficult to do in the outpatient setting. That may just be my limited experience speaking there, but from the relatively little outpatient work I've done I just think it's harder to do in that setting given the limited time for those encounters and the fact that I've found collecting collateral information to be far easier during inpatient rotations.
 
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I agree. But working 1-1 with an attending is double edged sword. I personally do not like 90% of the attending in the program and find their fund of knowledge pretty deficient. I would rather work 1-1 with a PGY3 or 4 whom I can learn a lot.
 
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I agree. But working 1-1 with an attending is double edged sword. I personally do not like 90% of the attending in the program and find their fund of knowledge pretty deficient. I would rather work 1-1 with a PGY3 or 4 whom I can learn a lot.
Yikes...
 

Mass Effect

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Well let's start with the obvious point of just identifying them. There's more time to do this on an inpatient unit and you have staff who can actually see behaviors and tendencies in person
...during an acute psychiatric illness. Sorry, but that's the exact opposite of the way you're supposed to diagnose a personality disorder. Diagnosing a personality disorder in someone you don't have a long-term relationship with during an acute illness is not a legit thing. People do it but they're doing it wrong. Outpatient doctors are the ones who establish those long-term relationships and hear about the patient's level of functioning at home, at work, and with friends. They hear about the patient's responses to stressful situations, the mood dysregulation and emotional lability, the friendships that fall by the wayside, the employment that's threatened or terminated. To suggest you'd do a better job of diagnosing a personality disorder when someone is acutely ill in an inpatient psych ward over 5 days is not realistic.
 
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Stagg737

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I had an attending like this on an audition rotation (at a program I did not end up at, thankfully). They were trying to teach me some neuro and how they relate to psych but it was very apparent that they didn't know neuro very well: insisted that Broca's and Wernicke's were the opposite of what they actually were, mixed up roles of various nuclei, a few other things I can't remember now but were definitely wrong when I went back and looked them up. Unfortunately, these people exist in residency programs, but hopefully are not the norm at a given program.

...during an acute psychiatric illness. Sorry, but that's the exact opposite of the way you're supposed to diagnose a personality disorder. Diagnosing a personality disorder in someone you don't have a long-term relationship with during an acute illness is not a legit thing. People do it but they're doing it wrong. Outpatient doctors are the ones who establish those long-term relationships and hear about the patient's level of functioning at home, at work, and with friends. They hear about the patient's responses to stressful situations, the mood dysregulation and emotional lability, the friendships that fall by the wayside, the employment that's threatened or terminated. To suggest you'd do a better job of diagnosing a personality disorder when someone is acutely ill in an inpatient psych ward over 5 days is not realistic.
Okay, I don't disagree with most of this, my biggest question is do you really have time in the outpatient setting to gather the collateral from other people? From the experiences I've had, it definitely seemed like this was accomplished better on inpatient rotations than in the outpatient setting. Sure, you hear from the patient over the course of several appointments, but I feel like getting info from close friends and family is also important in making a PD diagnosis and this is much easier to achieve in the inpatient setting. Maybe I've been fortunate to work on units where we had time to make calls and talk to visitors, but is this not generally the case?
 

Sushirolls

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...during an acute psychiatric illness. Sorry, but that's the exact opposite of the way you're supposed to diagnose a personality disorder. Diagnosing a personality disorder in someone you don't have a long-term relationship with during an acute illness is not a legit thing. People do it but they're doing it wrong. Outpatient doctors are the ones who establish those long-term relationships and hear about the patient's level of functioning at home, at work, and with friends. They hear about the patient's responses to stressful situations, the mood dysregulation and emotional lability, the friendships that fall by the wayside, the employment that's threatened or terminated. To suggest you'd do a better job of diagnosing a personality disorder when someone is acutely ill in an inpatient psych ward over 5 days is not realistic.
Axis II can be diagnosed inpatient, C/L or outpatient. Some times in a single consult or over continuity. Some patients can give a reflective enough history when you present to them the need to reflect over their whole life going back to teenage years, not just the past week, or year, or decade. Diagnosing axis II takes a little extra time whether you are inpatient or outpatient but either setting are equally capable of making it happen as long as you spend the time on it.

Anecdote of the moment: Saw one patient ~5 years ago, came in acute SI, had opioids, meth on board. Got over the acute meth psychosis. Went over the symptoms to teenage years, clearly borderline PD. Nixed the bipolar diagnosis. Laid out a chem dep treatment plan, encouraged DBT as part of it. Saw the patient 5 years later in different facility. Doing much better, acute depressive episode. And was gracious for the time spent at that moment, and since then was gracious for de-emphasizing role of medications and patient achieved sobriety (except cannabis) and continuing to work on DBT skills with an individual therapist. Expressed a greater life quality and appreciative of time spent all those years ago.
 
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clausewitz2

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Axis II can be diagnosed inpatient, C/L or outpatient. Some times in a single consult or over continuity. Some patients can give a reflective enough history when you present to them the need to reflect over their whole life going back to teenage years, not just the past week, or year, or decade. Diagnosing axis II takes a little extra time whether you are inpatient or outpatient but either setting are equally capable of making it happen as long as you spend the time on it.

Anecdote of the moment: Saw one patient ~5 years ago, came in acute SI, had opioids, meth on board. Got over the acute meth psychosis. Went over the symptoms to teenage years, clearly borderline PD. Nixed the bipolar diagnosis. Laid out a chem dep treatment plan, encouraged DBT as part of it. Saw the patient 5 years later in different facility. Doing much better, acute depressive episode. And was gracious for the time spent at that moment, and since then was gracious for de-emphasizing role of medications and patient achieved sobriety (except cannabis) and continuing to work on DBT skills with an individual therapist. Expressed a greater life quality and appreciative of time spent all those years ago.
There will of course be obvious cases that are obvious. If it is hit-you-over-the-head obvious then of course make the diagnosis.

I would however be cautious about doing this based on a single conversation with the patient alone during a period of acute distress, for a couple of reasons.

A) people with genuine hypomanic episodes often have really poor awareness of them

B) memory is an interpretive process and not like retrieving pictures from a camera. Someone withdrawing from opioids is going to be dysphoric. Their recall of their history is going to have a heavy patina of dysphoria stretched over everything. I can imagine this getting confused for BPD. Same goes for affective liability (which in and of itself is not diagnostic regardless but that doesn't stop some people from drawing that conclusion that rapid mood swings = borderline).

Not saying you did those things but this is a place to go lightly.
 
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Sushirolls

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I disagree. This is an area where we should plow full steam ahead. When do we not see patients in acute distress? A big chunk of our job is assessing reliability as historian and weeding thru the confounders of a differential. Sometimes you blaze a trail to a diagnosis, other times you get stuck in the muck. This is something that 4 years of residency should prepare people for. But you have to spend the extra time to explore those question paths (and have time to discuss positive findings).

A trickier part is how to discuss the diagnosis, educate on what it is, frame prognosis, and encourage treatment.
 

Sushirolls

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Outpatient.
LOL. Nah, distress still is happening in outpatient. Panic attacks, SI, relational discord, cannabis daily, alcohol daily, opioids daily, meth daily, about to be fired, EAP, short term disability, finances close to bankruptcy, domestic violence, child custody cases, etc...
 

hamstergang

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LOL. Nah, distress still is happening in outpatient. Panic attacks, SI, relational discord, cannabis daily, alcohol daily, opioids daily, meth daily, about to be fired, EAP, short term disability, finances close to bankruptcy, domestic violence, child custody cases, etc...
Of course there's distress everywhere, otherwise they wouldn't be our patients. But they're not always in acute distress when in an outpatient level of care. We can assess people when they're well in the outpatient world.
 
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Mass Effect

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Okay, I don't disagree with most of this, my biggest question is do you really have time in the outpatient setting to gather the collateral from other people? From the experiences I've had, it definitely seemed like this was accomplished better on inpatient rotations than in the outpatient setting. Sure, you hear from the patient over the course of several appointments, but I feel like getting info from close friends and family is also important in making a PD diagnosis and this is much easier to achieve in the inpatient setting. Maybe I've been fortunate to work on units where we had time to make calls and talk to visitors, but is this not generally the case?
Yes, you have time in the outpatient setting to gather collateral. You're not restricted on time, so if you can't do it the day of the appointment, you do it the next day, the day after that, or the day after that. But frankly, it isn't just about collateral and a diagnosis of a personality disorder shouldn't be made after one visit. You can and should have a differential, but you don't need to jump to such a diagnosis on first or second meeting. Never over nor undervalue collateral. For instance, a patient's sister is not an authority on the patient's friendships/romantic relationships. A patient's spouse is not an authority on the patient's work relationships. There's no substitute for watching the patient, him/herself, evolve and share details of his/her life.

Axis II can be diagnosed inpatient, C/L or outpatient. Some times in a single consult or over continuity. Some patients can give a reflective enough history when you present to them the need to reflect over their whole life going back to teenage years, not just the past week, or year, or decade. Diagnosing axis II takes a little extra time whether you are inpatient or outpatient but either setting are equally capable of making it happen as long as you spend the time on it.
Of course you can. You can also diagnose an 8 year old with bipolar disorder. Should you? Not in my opinion. Patients can reflect over their life, but their interpretation of their life at a time of acute illness may be different than their interpretation any other time. If you don't believe that, just ask a terminal cancer patient.

Anecdote of the moment: Saw one patient ~5 years ago, came in acute SI, had opioids, meth on board. Got over the acute meth psychosis. Went over the symptoms to teenage years, clearly borderline PD. Nixed the bipolar diagnosis. Laid out a chem dep treatment plan, encouraged DBT as part of it. Saw the patient 5 years later in different facility. Doing much better, acute depressive episode. And was gracious for the time spent at that moment, and since then was gracious for de-emphasizing role of medications and patient achieved sobriety (except cannabis) and continuing to work on DBT skills with an individual therapist. Expressed a greater life quality and appreciative of time spent all those years ago.
I'm of the opinion that anyone can benefit from DBT, especially someone with substance use.

I disagree. This is an area where we should plow full steam ahead. When do we not see patients in acute distress? A big chunk of our job is assessing reliability as historian and weeding thru the confounders of a differential. Sometimes you blaze a trail to a diagnosis, other times you get stuck in the muck. This is something that 4 years of residency should prepare people for. But you have to spend the extra time to explore those question paths (and have time to discuss positive findings).

A trickier part is how to discuss the diagnosis, educate on what it is, frame prognosis, and encourage treatment.
I actually think discussing and educating is the easier part. The fact is that on an inpatient unit, while you can see true BPD for what it is with clear examples in the patient's HISTORY, you should not make the diagnosis on present behavior and I'd be cautious about doing it from past behavior as well without fully understanding the context. In no other psych diagnosis is context as important as it is in personality disorders.
 

Stagg737

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I would however be cautious about doing this based on a single conversation with the patient alone during a period of acute distress,
Going back to the PD point, this isn't really what you're doing on an inpt unit though. You're interviewing them on a daily basis, sometimes multiple times in a day, gathering collateral, pushing and challenging them on various aspects as needed, watching them interact with other patients and staff yourself, gathering info from staff about how they are behaving in other interviews and while interacting with other patients. Sometimes this is for a couple days, sometimes for a couple weeks. So it's a lot more than just the one conversation in terms of gathering data.

We can assess people when they're well in the outpatient world.
Are they really well though? Per the DSM one of the criteria for all PDs is that that "the enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning", that they're inflexible and pervasive across a broad range of dimensions of an individuals life, and that these features are stable across a long duration. Sure they'll have good days and bad days, but in many cases I think you would still be able to gather that history through collateral during a hospitalization and even witness a fair amount of it yourself on the unit (assuming they're not intoxicated or psychotic).

If you're referring to their direct reason for hospitalization when you say well it's a better argument, but for most I think you could still get a fair picture for many of these individuals at the end of their hospitalization.

Patients can reflect over their life, but their interpretation of their life at a time of acute illness may be different than their interpretation any other time. If you don't believe that, just ask a terminal cancer patient.
While true, you should still be able to gauge whether this is the case when talking to family and friends, and if it is discordant then it can give you an idea as to whether their information in regards to PDs is valid.

For instance, a patient's sister is not an authority on the patient's friendships/romantic relationships. A patient's spouse is not an authority on the patient's work relationships. There's no substitute for watching the patient, him/herself, evolve and share details of his/her life.
True, but they will also be able to give you a different perspective on the patient and if you are able to obtain collateral from multiple people it can paint a completely different picture than what a patient may tell you. I've already had a few patient who gave off a feel for a certain PD (usually BPD or anti-social) who told me one thing but then talking to multiple friends and family members there was a completely different picture. A few of those times the patients agreed with what was said when they were called out on it or remembered things they had forgotten or didn't think were relevant. Not trying to overvalue collateral, but for some patients it's incredibly valuable and can sometimes completely change a treatment course.

I realize that some of this can be obtained during an outpt visit as well as an inpt stay, but I think there are certain things which can be seen while a patient is hospitalized that one just wouldn't be able to see during an outpt visit. I'm not saying it's better to diagnose a PD during an inpatient stay by any means. However, I don't think a long-term relationship is essential by any means for diagnosing many patients with PDs and that you can certainly make those diagnoses with good history, collateral, and observation on the unit as they improve (excluding certain situations like I mentioned above). I think that argument doesn't really give credence to the clinical work that can and should be done on an inpatient unit. I can also appreciate the advantages of the outpatient setting with the ability to develop long-term relationships though, especially for those patients whose PDs are more subtle or who were truly altered or uncooperative during the inpatient stay.
 
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Mass Effect

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In most cases, making the diagnosis of BPD on an inpatient unit is not going to change the treatment plan. You would just augment it.
 
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