Business/start-up opportunities as a psychiatrist

[shoenberg3]

Hello,

I am currently in med school, trying to decide between pursuing psychiatry (most likely), radiology (less so), and neurology (most unlikely).
I love everything about psychiatry except I also hold an entrepreneurial spirit and would love to explore the possibility of creating startups/businesses related to my chosen medical specialty.

I am aware that for radiology, there is quite a buzz with diagnostic imaging and AI -- which is something I would love to get involved with as a consultant/scientist (if I decide to pursue radiology).

It also appears that there is also a quite a lot of neurology startups (in fields of stem cell research, drug development, EEG wearables etc).

I am worried, however, that psychiatry offers less of these opportunities compared to radiology and neurology. However, I have done some research and found some areas that were sort of interesting -- such as app for CBT, retail psychiatry, treatment prediction research, digital phenotyping for mental illnesses etc.

Are there anyone here who is a psychiatrist and also pursue entrepreneurial endeavors?

Any insight would be highly appreciated!

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[finalpsychyear]

Hello,

I am currently in med school, trying to decide between pursuing psychiatry (most likely), radiology (less so), and neurology (most unlikely).
I love everything about psychiatry except I also hold an entrepreneurial spirit and would love to explore the possibility of creating startups/businesses related to my chosen medical specialty.

I am aware that for radiology, there is quite a buzz with diagnostic imaging and AI -- which is something I would love to get involved with as a consultant/scientist (if I decide to pursue radiology).

It also appears that there is also a quite a lot of neurology startups (in fields of stem cell research, drug development, EEG wearables etc).

I am worried, however, that psychiatry offers less of these opportunities compared to radiology and neurology. However, I have done some research and found some areas that were sort of interesting -- such as app for CBT, retail psychiatry, treatment prediction research, digital phenotyping for mental illnesses etc.

Are there anyone here who is a psychiatrist and also pursue entrepreneurial endeavors?

Any insight would be highly appreciated!

Your not going to make $ in psychiatry other than the standard 200-250k by the time your out with what is coming in medicine. The others you have a much greater chance but those are also going to be effected.

 

[clozareal]

Some ideas:
Check out Psychiatry Innovation Lab.
Also, check out the Mental Health Hackathon.

 

[BiscoDisco]

Your not going to make $ in psychiatry other than the standard 200-250k by the time your out with what is coming in medicine. The others you have a much greater chance but those are also going to be effected.

Why are you predicting drop in rates? Also 200 is far below standard.

 

[VA Hopeful Dr]

Why are you predicting drop in rates? Also 200 is far below standard.

Because doctors have been doing that since forever

 

[finalpsychyear]

Why are you predicting drop in rates? Also 200 is far below standard.

Most people in psychiatry and in medicine in general have poor business sense. Most people don't want to work 40+ hours. Not sure if there are more part timers in psych but I think so compared to other fields. Of the 7 in my graduating class 5 took jobs in academia/low pay settings and all were started on a salary 170-190 just a few years ago. My prediction is really for what i feel will be standard 10 years from now inflation adjusted I would hope.

 

[Extralong]

I would ignore the negative sounding salary talk. It isn’t accurate and always anecdotal.

Anyways, before turning this thread into how much a psychiatrist makes, let’s open the floor back up on business.

It’s unclear if you are interested in starting a business, or do something specific in tech? From a business aspect, psych has little overhead, from a tech perspective, there are treatment modalities that use devices and technologies.

I recommend browsing a bit on SDN in psychiatry as those topics have been discussed. Maybe there is something different you are asking and I’m not fully understanding.

 

[TexasPhysician]

A high percentage of psychiatrists have their own practice. We are generally quite entrepreneurial, but success rates vary. Mental health is a huge field with a lot happening.

 

[TexasPhysician]

If your key concern is making money then you should focus on conducting any procedures that you can - such as ECT, TMS, and even order CT and/or MRI scans for disorders which may exhibit overlaps with a neurological diagnosis. You need to make your psychiatric treatment as medical as possible to be able to receive higher compensation rates. Therapy does not compensate well at all, and psychiatrists are increasingly stripping this aspect of their treatment systems entirely as time goes on. This trend has been observed to a substantial degree within the past three or four decades.

You'd be hard pressed to make anything more than the 250,000-300,000 yearly standard in this field, unless you go all out and work surgeon hours (at least 90 hours a week) and manage to pull in over 500,000 annually. If you work full-time per week basis with weekends off, you will still be making near if not the top 1% of income among professionals in the country. You could get away with charging more per hour, especially during initial consultations, but you'd typically need experience for that kind of endeavor as well a VERY good reputation in the local community to have those rates pay off for you. Otherwise, you're a small fish in a big pond.

I haven’t seen any of the above to be true. About 60% of my fellow graduates just a few years out are earning $300k+ with no procedures and work 30-40 hr weeks. We are in different geographies and practices. I even know someone doing 90% therapy and grosses $300k+, and he is younger than me.

To avoid this turning into a salary thread, most of us are also doing something entrepreneurial. This includes real estate and start-ups not included in the financial numbers I mention above. Hopefully one day I’ll be able to say that a project of mine is wildly successful, but we will see.

The trend I see is that the entrepreneurial bunch earns more despite fewer hours and fewer patients. They aren’t afraid to change jobs or hold multiple PT jobs that pay more. This lends more time to grow other projects.

 

[psychapp121]

The thing about neurology is that in private practice you are still practicing as a fully clinical physician. There are no alternatives for neurologists in outpatient clinics, they still have to do physical exams, medication evaluations, imaging requests, etc. Psychiatrists, however, can base their own practice with a high focus on providing psychotherapy, which gives their private practice the potential to incorporate a freedom of employing various methods of treatment. Neurologists would still do what they always do, just in an office instead of a hospital.

Of course, radiology is a whole 'nother ball park.

Psychiatry is indeed a VERY cushy specialty and this is particularly why private outpatient practice makes it a very stable business that can be managed. You can focus on medication management, psychotherapy, or incorporate both depending on how you setup your schedule and your charging rates per hour. For an increase in reimbursement it is suggested you complete a fellowship, especially in an area such as neuropsychiatry if the biological aspects of psychiatry interest you.

If your key concern is making money then you should focus on conducting any procedures that you can - such as ECT, TMS, and even order CT and/or MRI scans for disorders which may exhibit overlaps with a neurological diagnosis. You need to make your psychiatric treatment as medical as possible to be able to receive higher compensation rates. Therapy does not compensate well at all, and psychiatrists are increasingly stripping this aspect of their treatment systems entirely as time goes on. This trend has been observed to a substantial degree within the past three or four decades.

You'd be hard pressed to make anything more than the 250,000-300,000 yearly standard in this field, unless you go all out and work surgeon hours (at least 90 hours a week) and manage to pull in over 500,000 annually. If you work full-time per week basis with weekends off, you will still be making near if not the top 1% of income among professionals in the country. You could get away with charging more per hour, especially during initial consultations, but you'd typically need experience for that kind of endeavor as well a VERY good reputation in the local community to have those rates pay off for you. Otherwise, you're a small fish in a big pond.

a lot of this is not accurate lol

 

[finalpsychyear]

I haven’t seen any of the above to be true. About 60% of my fellow graduates just a few years out are earning $300k+ with no procedures and work 30-40 hr weeks. We are in different geographies and practices. I even know someone doing 90% therapy and grosses $300k+, and he is younger than me.

To avoid this turning into a salary thread, most of us are also doing something entrepreneurial. This includes real estate and start-ups not included in the financial numbers I mention above. Hopefully one day I’ll be able to say that a project of mine is wildly successful, but we will see.

The trend I see is that the entrepreneurial bunch earns more despite fewer hours and fewer patients. They aren’t afraid to change jobs or hold multiple PT jobs that pay more. This lends more time to grow other projects.

I do an annual business discussion with 4th year residents from my residency program (east coast). Out of the typical 10 yearly soon to be attendings I get maybe half who have the drive and ambition to go for PP even in some limited capacity. In the 3 years I have been doing this I would say 3 total have actually gone through with it. Now these are all early career doctors and I'm sure more may eventually come on board.

Most are happy taking multiple positions or realizing that 200-250k is a ton of money with their current debt and prefer 30 hour 3-4 day work weeks or get pregnant and are doing PT employment models.

I also find the millennial generation and later all prioritizing the lifestyle element and quality of life above all else and believe that will only get stronger. The old school doctor mentality of work, work, work seems to be going away and it makes sense since most residencies in all fields are requiring much less hours than in the past. So if you came up training where your working 80-90 hours for 4 years in residency then working 50-60 as an attending seems so much better. However, if your residency program is barely pushing 40-50 max hours like mine was your going to find 30-40 as a threshold as an attending.

 

[TexasPhysician]

That's interesting, are they charging high rates per hour? Geographic location does make a difference, yes, but I could guarantee you if they are making $300,000 a year and perhaps more by just doing mostly therapy, they would make MUCH more by focusing on medication management. Psychopharmacology is heavily reimbursed and will continue to move so in this direction in the future, but a psychiatrist who can make that kind of money as a therapist has a seriously efficient business.

$160/hr jobs produce >$300k at 40 hrs/week. I don’t consider that a high hourly rate. I could throw a rock and hit a dozen of those. If you are willing to look enough, negotiate, travel, or whatever $180-200/hr is quite possible.

The psychiatrist I know that does mostly therapy is charging a high rate with very low overhead.

 

[Merovinge]

The old school doctor mentality of work, work, work seems to be going away and it makes sense since most residencies in all fields are requiring much less hours than in the past. So if you came up training where your working 80-90 hours for 4 years in residency then working 50-60 as an attending seems so much better. However, if your residency program is barely pushing 40-50 max hours like mine was your going to find 30-40 as a threshold as an attending.

Where in the world do you practice medicine? I'm very aware of several different gen surg and surgical sub-specialty residency hours at at least a dozen different programs and none are even in the stratosphere of 50 hours/week. Several still need to lie on duty hours from time to time.

 

[psychapp121]

Where in the world do you practice medicine? I'm very aware of several different gen surg and surgical sub-specialty residency hours at at least a dozen different programs and none are even in the stratosphere of 50 hours/week. Several still need to lie on duty hours from time to time.

he’s talking about psych residency I think

 

[dl2dp2]

300k is now MGMA standard average--JUST got this e-mail from a recruiter. 250k would be a facilities job at an east coast academic-ish shop, 350k for a private group in an unremarkable location with somewhat heavier hours.

People who have good business sense can build *highly* lucrative businesses in this field. Day programs, inpatient, high-end private practices--competition is also stiffer, as you are also competing with PhD/MBAs who are trying to build similar things. There are recent grads who build pass-through practices that end up with net Schedule C profit close to 7 figures. Senior private psychiatrists charge $300+ per hour even in secondary markets and $600+ in top markets. You CAN absolutely make as much or more than a radiologist, especially if you run your own practice.

Neurology is not as good a field these days in terms of lifestyle/salary ratio. Their average is maybe 10-20% higher, but the average work hours of a typical neurologist is MUCH higher, with brutal call schedules. Much harder to build solo/small office-based groups in neurology due to higher overhead. Neurology as a field decided that they want to go the route of cards/pulm with their specialized ICUs and endovascular procedures and 24/7 coverage. Yes you can make a LOT, but these are *not* "lifestyle" specialties by any stretch.

In terms of tech startups, etc. there's lots of stuff in mental health that you can contribute, but that's a separate topic. In particular, the issues emerging from doing tech startup work invariably comes from the tech startup ecosystem itself, rather than from being a psychiatrist: i.e. if you want to work in tech startup, the main issues have to do with the *process* of running a startup, rather than the content whether it's related to radiology or neurology or psychiatrist.

 

[splik]

300k is now MGMA standard average--JUST got this e-mail from a recruiter. 250k would be a facilities job at an east coast academic-ish shop, 350k for a private group in an unremarkable location with somewhat heavier hours.

Though I don't want to contribute to the derailment of this thread, as it as already veered well off topic:
For anyone who wants the real numbers, the last MGMA 2019 survey showed the median compensation for psychiatry for 2017-2018 was $276,439 and the mean was $294,973, with 75%ile $332,120, and 90%ile $433,853

For academics, per AAMC 2020 survey - the median compensation for an assistant professor was $217k (for instructor it was 198k), with $251k being the 75%ile. For the NE it was similar with $214k as median compensation for assistant professor (for instructor it was 198k), with 247k being the 75%ile.

Please note these are total compensation which is not just salary but also incentive and bonus pay. It does not include benefits.
The AAMC compensation definition is so expansive it is useless as it includes everything you earn above salary. They used to publish fixed/contractual salary statistics as well but I guess no longer.

These are also for employed positions. The interquartile range is much greater for those in private practice with many people earning much less and others earning multiples of what the typical salaried position offers.

 

[Mass Effect]

The thing about neurology is that in private practice you are still practicing as a fully clinical physician. There are no alternatives for neurologists in outpatient clinics, they still have to do physical exams, medication evaluations, imaging requests, etc. Psychiatrists, however, can base their own practice with a high focus on providing psychotherapy, which gives their private practice the potential to incorporate a freedom of employing various methods of treatment. Neurologists would still do what they always do, just in an office instead of a hospital.

Of course, radiology is a whole 'nother ball park.

Psychiatry is indeed a VERY cushy specialty and this is particularly why private outpatient practice makes it a very stable business that can be managed. You can focus on medication management, psychotherapy, or incorporate both depending on how you setup your schedule and your charging rates per hour. For an increase in reimbursement it is suggested you complete a fellowship, especially in an area such as neuropsychiatry if the biological aspects of psychiatry interest you.

If your key concern is making money then you should focus on conducting any procedures that you can - such as ECT, TMS, and even order CT and/or MRI scans for disorders which may exhibit overlaps with a neurological diagnosis. You need to make your psychiatric treatment as medical as possible to be able to receive higher compensation rates. Therapy does not compensate well at all, and psychiatrists are increasingly stripping this aspect of their treatment systems entirely as time goes on. This trend has been observed to a substantial degree within the past three or four decades.

You'd be hard pressed to make anything more than the 250,000-300,000 yearly standard in this field, unless you go all out and work surgeon hours (at least 90 hours a week) and manage to pull in over 500,000 annually. If you work full-time per week basis with weekends off, you will still be making near if not the top 1% of income among professionals in the country. You could get away with charging more per hour, especially during initial consultations, but you'd typically need experience for that kind of endeavor as well a VERY good reputation in the local community to have those rates pay off for you. Otherwise, you're a small fish in a big pond.

You lost me at suggesting ordering CT or MRI for compensation.

 

[VA Hopeful Dr]

You lost me at suggesting ordering CT or MRI for compensation.

If you read your own films, you can bill for that.

You can also own the machines themselves but you have to be careful to avoid Stark issues.

 

[psychapp121]

If you read your own films, you can bill for that.

You can also own the machines themselves but you have to be careful to avoid Stark issues.

read your own films? Have you everseen a psychiatrist in your life read their own films? Lol

 

[TexasPhysician]

read your own films? Have you everseen a psychiatrist in your life read their own films? Lol

The Amen clinic reads their own PET scans and who knows what else.

 

[psychapp121]

The Amen clinic reads their own PET scans and who knows what else.

the amen clinic is a fraud tho

 

[TexasPhysician]

the amen clinic is a fraud tho

You didn’t qualify your question about psychiatrists reading scans above. Haha. They exist, but I am not recommending we do this.

 

[psychapp121]

Well, you probably should. Since psychiatry is a medical specialty, it's quite bothersome that many are acting like therapists instead of medical doctors. Leave the social work to the psychologists.

lol

 

[WisNeuro]

Well, you probably should. Since psychiatry is a medical specialty, it's quite bothersome that many are acting like therapists instead of medical doctors. Leave the social work to the psychologists.

Leave the social work to social workers. I ain't doing no case management.

 

[dl2dp2]

Well, you probably should. Since psychiatry is a medical specialty, it's quite bothersome that many are acting like therapists instead of medical doctors. Leave the social work to the psychologists.

It would be nice if psychologists actually did social work. A lot of time [semi-]wealthy people would rather have me do their social work for $X because they (justifiably) understand that if they randomly retain a social worker the quality of the social work done will be substandard.

It's fine. As long as they pay.

And it's not even that rare. 20% of Americans who are married have a net worth ~ 2M. They and their children have plenty of mental illness.

What is the Average Net Worth by Age in America?

When I was in high school, my high school quarterly report card always told me which decile I was in with respect to grades. Every quarter - top 10%, 2nd

wallethacks.com

 

[WisNeuro]

It would be nice if psychologists actually did social work. A lot of time [semi-]wealthy people would rather have me do their social work for $X because they (justifiably) understand that if they randomly retain a social worker the quality of the social work done will be substandard.

It's fine. As long as they pay.

And it's not even that rare. 20% of Americans who are married have a net worth ~ 2M. They and their children have plenty of mental illness.

What is the Average Net Worth by Age in America?

When I was in high school, my high school quarterly report card always told me which decile I was in with respect to grades. Every quarter - top 10%, 2nd

wallethacks.com

If I was private practice, and they were paying out of pocket for my time, I'd do it. In the hospital, it's unbillable time for me. I do some organization/info gathering (e.g., resources for driving evals, different local dementia groups) but it's pretty limited. My schedule is pretty booked and out several months. I need to find some of these patients who want to pay me 3 figures an hour to do case management work. Start doing that in addition to expansion of forensic work, sounds like a pretty good chunk o change.

 

[WisNeuro]

Right, I forgot you guys do psychometric testing...

Well, many of us have people who do that for us. We interpret the testing. Reimburses better that way.

 

[splik]

read your own films? Have you everseen a psychiatrist in your life read their own films? Lol

Yes, I review images on a near daily basis in my clinical and forensic practice and teach residents how to review imaging.

Well, you probably should. Since psychiatry is a medical specialty, it's quite bothersome that many are acting like therapists instead of medical doctors. Leave the social work to the psychologists.

In addition to reviewing imaging etc I also provide psychotherapy which is an important therapeutic intervention. As most of the patients I see have a somatization or functional neurological disorder (i.e. medically explained physical symptoms), I am uniquely placed to treat these individuals. Psychotherapy is not social work though some social workers are skilled psychotherapists. Even though I am a neuropsychiatrist (or especially because), being a therapist is an important part of my identity, and is in no way incompatible with my physician identity. While I could make more if I were churning out the patients and not providing psychotherapy, very few people provide the services I can and so there is a need for my services providing specialist psychotherapeutic interventions. Also $350 per session is imho very fairly compensated for something I love doing.

 

[psychapp121]

Yes, I review images on a near daily basis in my clinical and forensic practice and teach residents how to review imaging.


In addition to reviewing imaging etc I also provide psychotherapy which is an important therapeutic intervention. As most of the patients I see have a somatization or functional neurological disorder (i.e. medically explained physical symptoms), I am uniquely placed to treat these individuals. Psychotherapy is not social work though some social workers are skilled psychotherapists. Even though I am a neuropsychiatrist (or especially because), being a therapist is an important part of my identity, and is in no way incompatible with my physician identity. While I could make more if I were churning out the patients and not providing psychotherapy, very few people provide the services I can and so there is a need for my services providing specialist psychotherapeutic interventions. Also $350 per session is imho very fairly compensated for something I love doing.

you read head CT and mri brains?

 

[Mass Effect]

Yes, I review images on a near daily basis in my clinical and forensic practice and teach residents how to review imaging.

In fairness, aren't you a neuropsychiatrist? Reading head imaging on a daily basis is standard in neuropsych. When was the last time you saw a general adult psychiatrist reading an MRI for MDD in a 34 yo female with a hx of MDD? Or GAD in a 29 yo with a hx of GAD? Most of a general adult psychiatrist's panel is likely to be the MDD and GAD rather than the panel specific to a neuropsychiatrist, which likely includes a lot of patients with cognitive problems, s/p TBI, dementia, s/p stroke, etc.

 

[psychapp121]

In fairness, aren't you a neuropsychiatrist? Reading head imaging on a daily basis is standard in neuropsych. When was the last time you saw a general adult psychiatrist reading an MRI for MDD in a 34 yo female with a hx of MDD? Or GAD in a 29 yo with a hx of GAD? Most of a general adult psychiatrist's panel is likely to be the MDD and GAD rather than the panel specific to a neuropsychiatrist, which likely includes a lot of patients with cognitive problems, s/p TBI, dementia, s/p stroke, etc.

isn’t reading head imaging like a fellowship after 5 year radiology lol..i sense a big lawsuit if a psychiatrist tried to read that ****..

 

[splik]

isn’t reading head imaging like a fellowship after 5 year radiology lol..i sense a big lawsuit if a psychiatrist tried to read that ****..

I'm not pretending to be a neuroradiologist. Much like neurologists over-read their own images, neuropsychiatrists do too. I look imaging (MRIs, FDG-PET, DaT etc) on a daily basis. I have been qualified as an expert in federal court. While there is always the risk that my credibility to review imaging could be impeached and testimony excluded, so far judges and attorneys are quite happy for me to opine on brain imaging as related to forensic neuropsychiatric matters given that it is in the scope of my daily practice and I teach, present, and publish on this topic.

I am not saying that most psychiatrists can or should to reviewing imaging (though I think residency programs should do a better job of teaching this), just that a subset of us (e.g. neuropsychiatrists, some geriatric psychiatrists and C-L psychiatrists, and academic psychiatrists doing neuroimaging research) that do.

 

[michaelrack]

It's great to look at your own imaging, but a radiologist should do the official read

 

[Mass Effect]

isn’t reading head imaging like a fellowship after 5 year radiology lol..i sense a big lawsuit if a psychiatrist tried to read that ****..

I doubt any psychiatrist is providing the official read. They're just saying they look at it and read it before/during patient visits (of course an official read comes from the radiologist). Neuropsychiatry is different than general psychiatry as there patient panels are different and in the programs with which I'm familiar, they actually get training in reading head imaging. In the combined programs, I imagine even more so since they complete a neuro residency.

 

[romanticscience]

Yes, I review images on a near daily basis in my clinical and forensic practice and teach residents how to review imaging.


In addition to reviewing imaging etc I also provide psychotherapy which is an important therapeutic intervention. As most of the patients I see have a somatization or functional neurological disorder (i.e. medically explained physical symptoms), I am uniquely placed to treat these individuals. Psychotherapy is not social work though some social workers are skilled psychotherapists. Even though I am a neuropsychiatrist (or especially because), being a therapist is an important part of my identity, and is in no way incompatible with my physician identity. While I could make more if I were churning out the patients and not providing psychotherapy, very few people provide the services I can and so there is a need for my services providing specialist psychotherapeutic interventions. Also $350 per session is imho very fairly compensated for something I love doing.

What type of therapy do you perform with these patients?


Sent from my iPhone using SDN

 

[splik]

What type of therapy do you perform with these patients?


Sent from my iPhone using SDN

It depends on the patient and the underlying diagnosis: for somatization I use affective cognitive behavior therapy, for patients with functional neurological disorders, you need to have a much more dynamically informed approach for patients with chronic symptoms. There are some manual for FND and PNES but I find them wanting and don't see how patients who weren't going to get better with some good psychoeducation anyway are going to be cured by these approaches. You really need to go after the affect in the room, through the transference to make meaningful headway. This may include a mentalization-based approach. I sometimes use some gestalt-based techniques (which are part of the affective CBT for somatization), and for hypnotizable patients (not all FND pts are highly hypnotizable but many are) I will use hypnosis. There is some data for mindfulness-based therapy but I personally don't use this. There's also some interesting work coming out about using motivational interviewing/enhacement to get PNES pts to engage in treatment. It's also essential to involve the partner, so I do some sessions with the couple to identify systemic contributors, relationship contingencies, and look to promote healthier ways for the patient to get their needs met in their relationship.

For patients with comorbid PTSD, I usually refer out unless it only becomes evident much later and then treat w/ CPT or interpersonal psychotherapy.

I refer patients with comorbid borderline personality disorder out. It's not that I don't enjoy BPD patients (I do). It's that they need longer term treatment than I can provide and I don't provide DBT which a lot of them can use to manage their FND/PNES symptoms.

 

[dl2dp2]

If I was private practice, and they were paying out of pocket for my time, I'd do it. In the hospital, it's unbillable time for me. I do some organization/info gathering (e.g., resources for driving evals, different local dementia groups) but it's pretty limited. My schedule is pretty booked and out several months. I need to find some of these patients who want to pay me 3 figures an hour to do case management work. Start doing that in addition to expansion of forensic work, sounds like a pretty good chunk o change.

It depends on what kind of hospital you are talking about. Plenty of hospitals more or less explicitly pay MDs to do social work for their favorite customers.

 

[WisNeuro]

It depends on what kind of hospital you are talking about. Plenty of hospitals more or less explicitly pay MDs to do social work for their favorite customers.

Probably not our hospital. This system lost nearly 100 mil last year.

 

[psychapp121]

It depends on the patient and the underlying diagnosis: for somatization I use affective cognitive behavior therapy, for patients with functional neurological disorders, you need to have a much more dynamically informed approach for patients with chronic symptoms. There are some manual for FND and PNES but I find them wanting and don't see how patients who weren't going to get better with some good psychoeducation anyway are going to be cured by these approaches. You really need to go after the affect in the room, through the transference to make meaningful headway. This may include a mentalization-based approach. I sometimes use some gestalt-based techniques (which are part of the affective CBT for somatization), and for hypnotizable patients (not all FND pts are highly hypnotizable but many are) I will use hypnosis. There is some data for mindfulness-based therapy but I personally don't use this. There's also some interesting work coming out about using motivational interviewing/enhacement to get PNES pts to engage in treatment. It's also essential to involve the partner, so I do some sessions with the couple to identify systemic contributors, relationship contingencies, and look to promote healthier ways for the patient to get their needs met in their relationship.

For patients with comorbid PTSD, I usually refer out unless it only becomes evident much later and then treat w/ CPT or interpersonal psychotherapy.

I refer patients with comorbid borderline personality disorder out. It's not that I don't enjoy BPD patients (I do). It's that they need longer term treatment than I can provide and I don't provide DBT which a lot of them can use to manage their FND/PNES symptoms.

wow..I’m pretty sure my attendings would not even know where to begin to do what you mentioned and sure as hell don’t read their own scans or anything resembling that on the inpatient unit

 

[WisNeuro]

Reviewing your own scans is essential in the neurological/psychiatric arena. Neuroradiologists have a tendency to copy and paste a little too much, and confine their impressions very narrowly to the referral question. Also, I've found that the phrase "mild generalized atrophy" is used in a wide variety of degrees of atrophy, as well as missing some very circumscribed atrophy patterns (e.g., hippocampal, PCA, CBD, etc).

 

[liquidshadow22]

splik, did you compl

I'm not pretending to be a neuroradiologist. Much like neurologists over-read their own images, neuropsychiatrists do too. I look imaging (MRIs, FDG-PET, DaT etc) on a daily basis. I have been qualified as an expert in federal court. While there is always the risk that my credibility to review imaging could be impeached and testimony excluded, so far judges and attorneys are quite happy for me to opine on brain imaging as related to forensic neuropsychiatric matters given that it is in the scope of my daily practice and I teach, present, and publish on this topic.

I am not saying that most psychiatrists can or should to reviewing imaging (though I think residency programs should do a better job of teaching this), just that a subset of us (e.g. neuropsychiatrists, some geriatric psychiatrists and C-L psychiatrists, and academic psychiatrists doing neuroimaging research) that do.

did you complete a neuropsych fellowship?

 

[clozareal]

read your own films? Have you everseen a psychiatrist in your life read their own films? Lol

As splik does, I too read my own images always and add in comments if the radiologists don't comment on something, which is something the behavioral neurologists ingrained me during my rotation there. I also did as many electives in neuroradiology as I could in medical school. I probably read CTs, MRIs, and FDG-PET on a weekly basis as a resident, but that's also because I see a lot of geriatric patients, neuro-onc patients, patients getting ECT and TMS, and patients on the consult service.

Well, you probably should. Since psychiatry is a medical specialty, it's quite bothersome that many are acting like therapists instead of medical doctors. Leave the social work to the psychologists.

Psychiatrists are trained in both physiology/medicine and in psychotherapy as our core competencies in residency. What sets psychiatrists apart from primary care providers, psychiatric NPs, and psychiatric PAs on the one hand, and from psychologists (in most states) on the other, is that psychiatrists have been trained in both psychotherapy and pharmacotherapy, and in the integration of the two modalities. This, to me, is clearly the top of the psychiatric license: to know how to integrate psychotherapy and medications in ways that enhance outcomes, and to know which patients would benefit most from combined treatment. I don't buy into your notion that we should throw away half of our training and half of our skills.

 

[WisNeuro]

Well, in that case, psychologists are pretty much redundant then outside the scope of research/psychometric testing.

Depends, we generally see your therapy training on par in terms of stringency with how you all generally view RxP training. It's generally not even close for most programs. Some people go above and beyond and get great training in therapy in psychiatry, but most of what I see is pretty minimal compared to the average PhD.

 

[SourceOfDenial]

As splik does, I too read my own images always and add in comments if the radiologists don't comment on something, which is something the behavioral neurologists ingrained me during my rotation there. I also did as many electives in neuroradiology as I could in medical school. I probably read CTs, MRIs, and FDG-PET on a weekly basis as a resident, but that's also because I see a lot of geriatric patients, neuro-onc patients, patients getting ECT and TMS, and patients on the consult service.



Psychiatrists are trained in both physiology/medicine and in psychotherapy as our core competencies in residency. What sets psychiatrists apart from primary care providers, psychiatric NPs, and psychiatric PAs on the one hand, and from psychologists (in most states) on the other, is that psychiatrists have been trained in both psychotherapy and pharmacotherapy, and in the integration of the two modalities. This, to me, is clearly the top of the psychiatric license: to know how to integrate psychotherapy and medications in ways that enhance outcomes, and to know which patients would benefit most from combined treatment. I don't buy into your notion that we should throw away half of our training and half of our skills.

Ha, psychiatry psychotherapy training from the majority of programs in the country is pretty terrible. The level of supervision and case volume in a typical clinical PhD program is far greater.

 

[BiscoDisco]

Was thinking about this the other day. If you're a biologically oriented psychiatrist how do you go about working with personality disordered individuals, or those with significant PTSD trauama? Do you just refer out?

 

[TexasPhysician]

Was thinking about this the other day. If you're a biologically oriented psychiatrist how do you go about working with personality disordered individuals, or those with significant PTSD trauama? Do you just refer out?

Yes. I have counselors for this

 

[clausewitz2]

Was thinking about this the other day. If you're a biologically oriented psychiatrist how do you go about working with personality disordered individuals, or those with significant PTSD trauama? Do you just refer out?

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[SourceOfDenial]

Was thinking about this the other day. If you're a biologically oriented psychiatrist how do you go about working with personality disordered individuals, or those with significant PTSD trauama? Do you just refer out?

This is my rub with psychiatry (and more broadly medicine). People do not exist as a disease. Biologically oriented or not, if you just think of patients in a strict biomedical framework you’re failing as a clinician.

 

[dl2dp2]

This is the kind of input I like to see. Psychologists can only use therapy and psychometric testing, therefore it should make sense that they specialize in these kinds of treatment. Psychiatry should focus more on biological foundations of mental diseases, because there's no point in mixing therapeutic treatment with medication if you can learn so much more in a PhD program. If therapy is your main focus, you should have no business becoming a psychiatrist.

Was thinking about this the other day. If you're a biologically oriented psychiatrist how do you go about working with personality disordered individuals, or those with significant PTSD trauama? Do you just refer out?

Two unrelated issues: one is whether psychiatry training per se can be proficient for therapy; two is whether specific psychiatrists can deliver combined treatment that is better than split treatment.

In general, psychiatrists nation-wide are not as well trained in psychotherapy as a PhD psychologist, and especially once you are in practice for a number of years, psychiatrist by-and-large no long practice psychotherapy. As an average psychiatrist doing average general psychiatry you would not aim for doing predominantly psychotherapy or combined practice. Much like a general surgeon would mainly do choles and appys and not aim for some complicated liver surgery. That's true.

However, in subspecialist settings, there are psychiatrists who are comparably more skilled and experienced in therapy than most general PhD psychologists for specific kinds of psychotherapy. For example, in my experience, with a fellowship, I'm a much better substance abuse psychotherapist than a PhD psychotherapy with no subspecialist training. Complicated patients who have comorbidities prefer combined treatment. Similarly, psychiatrists who focus their practice on borderlines and and have specific training on TFP/DBT, etc. are usually better therapists than a general PhD psychologist.

 

[clausewitz2]

This is my rub with psychiatry (and more broadly medicine). People do not exist as a disease. Biologically oriented or not, if you just think of patients in a strict biomedical framework you’re failing as a clinician.

I was going to say if you are trying to help people address and modify their experiences and behaviors via psychotropic drugs without being cognizant of psychotherapeutic principles at all times you are dumber than a bag of hammers, but you put it much nicer.