Pharmohaulic

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Since diabetes often can affect a person's mental state, can a psychiatrist treat diabetes? Or would they get into trouble with their boards since that technically is an endocrine issue?
 

Bartelby

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On the inpatient unit, yes. Typically that means continuing or tweaking what the person is already taking. In the outpatient setting, no. It would likely be considered practicing beyond your scope of practice.
 
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Pharmohaulic

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On the inpatient unit, yes. Typically that means continuing or tweaking what the person is already taking. In the outpatient setting, no. It would likely be considered practicing beyond your scope of practice.
So they can tweak like the insulin and such?
 

SomeDoc

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1) Since diabetes often can affect a person's mental state, can a psychiatrist treat diabetes?
2) Or would they get into trouble with their boards since that technically is an endocrine issue?
1) Yes
2) If there is an adverse outcome, and if there exist specialists who treat said condition in the area, then the answer is "maybe." For a single case, it is more likely that a civil suit for malpractice would be filed, than the board getting involved. State boards are concerned with minimally acceptable standards of care, and issues related to public safety (ie, a state board would be more likely to initiate a probable cause review against a practitioner if there are reports of repeated adverse outcomes that are outside the scope of a given practitioner).

With regards to board action and/or civil suit, a practitioner is less likely to be found liable (though still possible) if a specialist is not available in the area, and the practice was performed according to acceptable community and/or professional standards of care.

Too long didn't read:
Practice within your scope of specialization, refer to a qualified specialist where appropriate
 
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TikiTorches

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1) Yes
2) If there is an adverse outcome, and if there exist specialists who treat said condition in the area, then the answer is "maybe." For a single case, it is more likely that a civil suit for malpractice would be filed, than the board getting involved. State boards are concerned with minimally acceptable standards of care, and issues related to public safety (ie, a state board would be more likely to initiate a probable cause review against a practitioner if there are reports of repeated adverse outcomes that are outside the scope of a given practitioner).

With regards to board action and/or civil suit, a practitioner is less likely to be found liable (though still possible) if a specialist is not available in the area, and the practice was performed according to acceptable community and/or professional standards of care.

Too long didn't read:
Practice within your scope of specialization, refer to a qualified specialist where appropriate
Yes. You don't want to be on the other end of a plaintiff lawyer in this case.

But a psychiatrist is a physician and can manage these illnesses if they want to.
 
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st2205

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1. Can a psychiatrist treat diabetes? Yes, any fully licensed physician could legally treat anything. As physicians, psychiatrists should be at least minimally competent in basic general medical care (theoretically).
2. Do psychiatrists treat diabetes? No, not really, aside from what was mentioned above (inpatient units, small tweaks if nobody is available, etc.)
3. I sometimes start Metformin on patients when initiating antipsychotics (really only do this for Zyprexa), but I'm not treating diabetes so much as I'm looking to prevent it along with all the other metabolic side effects. If they actually had these problems, I'd be deferring this to someone else.
4. No psychiatrists are opening diabetes clinics or touting themselves as such.
5. Just because you can, doesn't mean you should. Legally authorized and malpractice are not mutually exclusive.
 

masterofmonkeys

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I'll do it as a stopgap, for antipsychotics, and for weight loss. I won't be their primary diabetes doc though.
 

OldPsychDoc

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Don't let the Nays above discourage you from learning all you possibly can about common diseases like this--tons of our patients have this problem, and we are part of the identification and monitoring of these things (they may see us every month--their PCP once a year, if that). Treating mental illness also has a huge effect on motivating patients to attend to their self cares and overall health.
 

clausewitz2

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Don't let the Nays above discourage you from learning all you possibly can about common diseases like this--tons of our patients have this problem, and we are part of the identification and monitoring of these things (they may see us every month--their PCP once a year, if that). Treating mental illness also has a huge effect on motivating patients to attend to their self cares and overall health.
In before vistaril appears to insist that no psychiatrist has had any role in managing a medical condition ever.
 
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splik

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In some outpatient settings such as assertive community treatment where there isn't a PCP, the psychiatrist may sometimes act as the PCP (including treating diabetes) because cardiovascular mortality is a big killer in the seriously mentally ill, and these patients are hard for even the mental health team to engage with, let alone primary care, thus it can be ethically justified. and of course these patients are not going to sue for malpractice. Other than that outpatient psychiatrists wouldn't manage diabetes. In the inpatient setting, most places would have a PCP/NP or something dealing with the medical problems of patients with the exception of many academic medical centers where it is common for psychiatrists (typically the residents) to manage the basic medical problems which might involve fiddling with insulin. I used to manage this by myself as a junior resident, but at this point I can't remember how to do it!
 
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AcronymAllergy

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From the outside looking in, I've seen psychiatrist colleagues address the issue in their appointments (e.g., educating about what lab values mean, checking on med adherence, etc.), but don't know of any who would initiate or significantly alter existing treatments. We have both primary care and a diabetes clinic in-house, though, and the average patient tends to be fairly complex.
 

clausewitz2

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So far in residency on psych rotations I "treat" it by ordering low dose sliding scale humalog, continuing or starting metformin (though we have to check a Cr first, pharmacy insists) and making sure our in-house medical team knows they are coming if they have had glycemic control issues in the past.

But then, this is a psych ED, so intensive management isn't really on the table. And yeah, I'm a resident, but we do genuinely have attendings working here at all times (with a brief window of an exception around midnight), so it is possible to do it at your grown-up job in psychiatry as well.
 

Salpingo

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Don't let the Nays above discourage you from learning all you possibly can about common diseases like this--tons of our patients have this problem, and we are part of the identification and monitoring of these things (they may see us every month--their PCP once a year, if that). Treating mental illness also has a huge effect on motivating patients to attend to their self cares and overall health.
I think its good to learn about it in residency, but I hope that I'm not worrying about it as an attending. Diabetes effects every organ system, but you don't see ophthalmologists treating it because it can effect vision, or surgeons treating it because it effects healing/recovery, etc. They'd rather focus on doing/cutting their area of interest. Similarly, I think our time is best spent figuring out why the person isn't taking care of themselves (with enough medical background to figure out what that would look like). The best diabetes regimen in the world isn't going to lower your A1C one bit if you don't take it, and patients not taking their meds are our bread and butter.
 

nancysinatra

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I think its good to learn about it in residency, but I hope that I'm not worrying about it as an attending. Diabetes effects every organ system, but you don't see ophthalmologists treating it because it can effect vision, or surgeons treating it because it effects healing/recovery, etc. They'd rather focus on doing/cutting their area of interest. Similarly, I think our time is best spent figuring out why the person isn't taking care of themselves (with enough medical background to figure out what that would look like).
The problem with your argument about ophthalmologists and surgeons is that neither of them are forced to spend the majority of their careers dealing with chronic illnesses that are managed medically, not surgically. The reason ophthos and surgeons are able to "focus on doing/cutting their area of interest" is because a) they are paid really well for their procedures, and b) they have carved out very lucrative niche specialties for themselves. They (and their patients), in many cases, can afford to blow off all the chronic medical stuff, knowing a more mundane field like medicine, peds, or psych will handle it. Medicine is overflowing with poorly controlled diabetics, and some of that runs over to psych. I say there is no reason a psychiatrist shouldn't be able to manage Type II non-insulin dependent diabetes on at least a temporary basis.

The best diabetes regimen in the world isn't going to lower your A1C one bit if you don't take it, and patients not taking their meds are our bread and butter.
When you find a solution to the problem of patients not taking their meds, can you let us all know? Thanks.
 
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The problem with your argument about ophthalmologists and surgeons is that neither of them are forced to spend the majority of their careers dealing with chronic illnesses that are managed medically, not surgically. The reason ophthos and surgeons are able to "focus on doing/cutting their area of interest" is because a) they are paid really well for their procedures, and b) they have carved out very lucrative niche specialties for themselves. They (and their patients), in many cases, can afford to blow off all the chronic medical stuff, knowing a more mundane field like medicine, peds, or psych will handle it. Medicine is overflowing with poorly controlled diabetics, and some of that runs over to psych. I say there is no reason a psychiatrist shouldn't be able to manage Type II non-insulin dependent diabetes on at least a temporary basis.



When you find a solution to the problem of patients not taking their meds, can you let us all know? Thanks.
Operant conditioning. If you have to go much further than that then a bit of Motivational Interviewing to assess readiness for change and identify where the resistance is coming from so that you can target the right behaviors for reinforcement. It actually isn't that complicated, but most people seem to just waste a lot of time telling people what to do and then are surprised or frustrated when they don't do what they are told.
 

clausewitz2

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Operant conditioning. If you have to go much further than that then a bit of Motivational Interviewing to assess readiness for change and identify where the resistance is coming from so that you can target the right behaviors for reinforcement. It actually isn't that complicated, but most people seem to just waste a lot of time telling people what to do and then are surprised or frustrated when they don't do what they are told.
"Patient is not doing what I have harangued them for not doing, suspect antisocial personality disorder"
 

Salpingo

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The problem with your argument about ophthalmologists and surgeons is that neither of them are forced to spend the majority of their careers dealing with chronic illnesses that are managed medically, not surgically. The reason ophthos and surgeons are able to "focus on doing/cutting their area of interest" is because a) they are paid really well for their procedures, and b) they have carved out very lucrative niche specialties for themselves. They (and their patients), in many cases, can afford to blow off all the chronic medical stuff, knowing a more mundane field like medicine, peds, or psych will handle it. Medicine is overflowing with poorly controlled diabetics, and some of that runs over to psych. I say there is no reason a psychiatrist shouldn't be able to manage Type II non-insulin dependent diabetes on at least a temporary basis.
I was trying to be humorous with the surgery reference, but its true for any specialty. For example, diabetes has huge implications in neurology, but they don't manage it. The reason isn't economic, they have a set of skills and training and they want to put it to use -- maybe they start metformin, but they're not discussing insulin sliding scales or prescribing the latest glyburidysidyl agent. We actually can do some good taking care of mental illness. Treating depression in patients that have it and coordinating with PMDs has a significant impact on A1C (see: http://www.nejm.org/doi/full/10.1056/NEJMoa1003955).

Sponging up the run-off from the less "mundane" specialties who are too busy making money is something that can be handled (and handled well) by midlevels, such as family medicine NPs and PAs.

When you find a solution to the problem of patients not taking their meds, can you let us all know? Thanks.
Its not that psychiatrists have a solution, I just generally walk into the room under the assumption that the patient is not taking their medications (with the exception of benzos and stimulants for adults). That changes the nature of the conversation and management. My experience with other rotations is that if you prescribe a medication and it doesn't work, the assumption is that the medication didn't work. They also don't have the time in an appointment to address it. By actually addressing the reasons they are and aren't taking medications, you get a chance to figure out strategies and techniques to help, as opposed to instinctively changing the dosage or adding something new. We also have more clinical contact with our patients, with more opportunities for motivational interviewing (like STP mentioned) and general nagging.
 

Dharma

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From what I've seen, there are basics we should be able to manage on our own in terms of inpatient. Or you can be like some attendings and consult medicine for every little blip on the radar. Shouldn't be too hard to restart metformin (and maybe even order glucose readings if need be) for those decently managed patients. Anything requiring tricky 2nd or 3rd line agents deserve a consult/curbside. Knowing when to bother, I mean consult medicine is a skill we should be developing I'm guessing. (/mini rant)
 
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michaelrack

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3 models of inpatient psych: 1) GP or NP supervised by a GP sees every patient, 2) psych consults gp or np for patients with significant medical problems (DM with blood sugars in the 300's) and 3) psych is supposed to to handle most medical issues themselves and only consult medicine for severe medical problems requiring immediate treatment (can't keep blood sugar under 450).
 

nancysinatra

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I was trying to be humorous with the surgery reference, but its true for any specialty. For example, diabetes has huge implications in neurology, but they don't manage it. The reason isn't economic, they have a set of skills and training and they want to put it to use -- maybe they start metformin, but they're not discussing insulin sliding scales or prescribing the latest glyburidysidyl agent. We actually can do some good taking care of mental illness. Treating depression in patients that have it and coordinating with PMDs has a significant impact on A1C (see: http://www.nejm.org/doi/full/10.1056/NEJMoa1003955).

Sponging up the run-off from the less "mundane" specialties who are too busy making money is something that can be handled (and handled well) by midlevels, such as family medicine NPs and PAs.



Its not that psychiatrists have a solution, I just generally walk into the room under the assumption that the patient is not taking their medications (with the exception of benzos and stimulants for adults). That changes the nature of the conversation and management. My experience with other rotations is that if you prescribe a medication and it doesn't work, the assumption is that the medication didn't work. They also don't have the time in an appointment to address it. By actually addressing the reasons they are and aren't taking medications, you get a chance to figure out strategies and techniques to help, as opposed to instinctively changing the dosage or adding something new. We also have more clinical contact with our patients, with more opportunities for motivational interviewing (like STP mentioned) and general nagging.
So, when you walk into the room, the patient is not taking the medication, and when you walk out of the room, they either are taking the medication or some other solution to their problem has been devised? Do I understand correctly? If so please take a pause to accept:

Nobel Prize

(For which I regrettably do not have an emoticon!)
 

jettavr6

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I've never been comfortable treating diabetes - although I've given Metformin a few times.
 
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Similar question: I am very interested in CAP (MS4, applying this year for residency/ fast tracks). I have a lot of elective experience in contraception counseling and would like to be able to manage contraceptive care in adolescent patients I am starting on teratogenic psychiatric medications as I may be the provider the patient sees most often rather than a pcp every 1-2 years. Would prescribing OCPs or becoming nexplanon certified be outside the scope of practice? I love IUDs as a contraceptive option but I feel like a psychiatrist doing a pelvic exam could damage the therapeutic alliance and so I would refer for that but for things that don't require a pelvic exam would that be ok?
 
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splik

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Similar question: I am very interested in CAP (MS4, applying this year for residency/ fast tracks). I have a lot of elective experience in contraception counseling and would like to be able to manage contraceptive care in adolescent patients I am starting on teratogenic psychiatric medications as I may be the provider the patient sees most often rather than a pcp every 1-2 years. Would prescribing OCPs or becoming nexplanon certified by outside the scope of practice? I love IUDs as a contraceptive option but I feel like a psychiatrist doing a pelvic exam could damage the therapeutic alliance and so I would refer for that but for things that don't require a pelvic exam would that be ok?
Well here's the thing. As a physician you can prescribe most things as a psychiatrist including contraception. However if you were working for a hospital, community mental health center, or HMO, you likely would not be able to do this. Your employer probably wouldn't be keen on it, and there are logistical issues about providing LARCs (i.e. you likely wouldn't have access to depoprovera or nexplanon in psychiatric settings). Also if you are not providing some forms of contraception then you are incentivized to provide others and despite people always claiming to the contrary, we know that this does influences how we practice, so might be ethically questionably to not be providing IUDs (though it is asking for trouble for a psychiatrist to do this). If the patient has a PCP or gynecologist then they should be managing this. These drugs can of course adversely effect psychiatric disorders and psychiatrists definitely have a role in monitoring that and advising more appropriate alternatives, and considering interactions (particularly for anticonvulsants). As for prescribing nexplanon I can imagine some poor schizophrenic patient thinking "my psychiatrist has put some tracking device in my arm and is using it to control me," and it is that kind of population that it may be the most legit to prescribe such a thing as patients who are better insured or less ill should have a PCP and more affluent patients (particularly psychotherapy pts) are not going to want their therapist putting nexplanon in them (though they may well want you prescribing the COC). In that setting, you are probably not going to be checking their BP when they come and see you though, and they will probably get annoyed with you if you do. Additionally, by performing this service you may discourage them from seeing a PCP/gynecologist for other routine care, such as pap screening, STD testing and so on.

The main setting where it would be appropriate someone on a LARC is in inpatient unit especially if you are going to be starting the patient (and particularly a bipolar patient) on a teratogenic drug. It might be appropriate to prescribe Plan B to a patient in the course of treatment though of course this now available over the counter.

Psychiatrists should definitely asking about contraception and pregnancy planning with patients, and consider the medications they prescribe. For example depakote is not recommended in women of childbearing age (though frequently used), and if you are using certain medications you definitely want the patients to be on LARCs. However, this should usually be managed by someone else. Another thing to bear in mind is you have limited time with your patients in which you want to focus on their mental health care - if you try to do it all, then you are shortchanging your patients.

Using oestrogens may have their role in treating certain kinds of mood disorders in women (for example PMDD or perimenopausal mood disorders) and in this case, it would definitely be appropriate for a psychiatrist to prescribe these drugs. Depoprovera is sometimes used in the management of sex offenders, pedophilic disorder, or sex addiction, though depending on the setting, it may not be the psychiatrist who is prescribing or administering this.
 

Salpingo

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Similar question: I am very interested in CAP (MS4, applying this year for residency/ fast tracks). I have a lot of elective experience in contraception counseling and would like to be able to manage contraceptive care in adolescent patients I am starting on teratogenic psychiatric medications as I may be the provider the patient sees most often rather than a pcp every 1-2 years. Would prescribing OCPs or becoming nexplanon certified by outside the scope of practice? I love IUDs as a contraceptive option but I feel like a psychiatrist doing a pelvic exam could damage the therapeutic alliance and so I would refer for that but for things that don't require a pelvic exam would that be ok?
Practically, this won't come up too often. The biggest teratogen offender is Depakote, and I consider that the absolute last line agent for adolescent women (weight gain, alopecia, sedation). I guess you would also start OCPs for carbamazepine, paroxetine (rarely used for kids) and benzos (also hopefully not used for adolescents). The evidence on lithium is now looking more mixed. But as splik alluded to, if you are worried about your manic/borderline patient having unprotected sex, they should really be getting good gyn/STD follow-up for a whole host of reasons. I'll generally refill a non-psych prescription if needed once, but if it becomes a repeat issue, I'll start questioning why they aren't going to their PMD. Ultimately, I think its more fulfilling to work with other providers that you trust over signing a prescription. Also good for referrals.

Its worth considering a Triple Board if you're interested in providing holistic care to adolescent women, or specializing in reproductive psych, where you can consult on interesting cases to optimize hormonal agents for mental health. I saw a case of menstrual psychosis that was treated with a psychologically-minded gynecologist (although I suppose we could have used a medically-minded psychiatrist). If you're interested in working with intellectually disabled, that's a pretty vulnerable population.
 
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Well here's the thing. As a physician you can prescribe most things as a psychiatrist including contraception. However if you were working for a hospital, community mental health center, or HMO, you likely would not be able to do this. Your employer probably wouldn't be keen on it, and there are logistical issues about providing LARCs (i.e. you likely wouldn't have access to depoprovera or nexplanon in psychiatric settings). Also if you are not providing some forms of contraception then you are incentivized to provide others and despite people always claiming to the contrary, we know that this does influences how we practice, so might be ethically questionably to not be providing IUDs (though it is asking for trouble for a psychiatrist to do this). If the patient has a PCP or gynecologist then they should be managing this. These drugs can of course adversely effect psychiatric disorders and psychiatrists definitely have a role in monitoring that and advising more appropriate alternatives, and considering interactions (particularly for anticonvulsants). As for prescribing nexplanon I can imagine some poor schizophrenic patient thinking "my psychiatrist has put some tracking device in my arm and is using it to control me," and it is that kind of population that it may be the most legit to prescribe such a thing as patients who are better insured or less ill should have a PCP and more affluent patients (particularly psychotherapy pts) are not going to want their therapist putting nexplanon in them (though they may well want you prescribing the COC). In that setting, you are probably not going to be checking their BP when they come and see you though, and they will probably get annoyed with you if you do. Additionally, by performing this service you may discourage them from seeing a PCP/gynecologist for other routine care, such as pap screening, STD testing and so on.

The main setting where it would be appropriate someone on a LARC is in inpatient unit especially if you are going to be starting the patient (and particularly a bipolar patient) on a teratogenic drug. It might be appropriate to prescribe Plan B to a patient in the course of treatment though of course this now available over the counter.

Psychiatrists should definitely asking about contraception and pregnancy planning with patients, and consider the medications they prescribe. For example depakote is not recommended in women of childbearing age (though frequently used), and if you are using certain medications you definitely want the patients to be on LARCs. However, this should usually be managed by someone else. Another thing to bear in mind is you have limited time with your patients in which you want to focus on their mental health care - if you try to do it all, then you are shortchanging your patients.

Using oestrogens may have their role in treating certain kinds of mood disorders in women (for example PMDD or perimenopausal mood disorders) and in this case, it would definitely be appropriate for a psychiatrist to prescribe these drugs. Depoprovera is sometimes used in the management of sex offenders, pedophilic disorder, or sex addiction, though depending on the setting, it may not be the psychiatrist who is prescribing or administering this.
Wow. Thank you very much for your long and well though out answer. I hadn't even thought about the incentivization of certain contraceptive methods and many of your other points. I am obviously early in my training but I have seen a lot of providers ignore things in a "not my circus, not my monkeys" approach to care and things like contraception falling through the cracks and I just want that to not be me as a future provider. Thanks!
 

takeeacy

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This is not to be taken too seriously, but I could imagine certain public/patient reactions along the lines of: "Psychiatrist sterilizes the mentally ill!!! or "Mentally ill patients denied their reproductive rights!!!" This could be a problem with Cluster B patients who end up trying to blame something on you.
 

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How I treat diabetes. I have a patient with diabetes on zyprexa and change them to something else, along with encouraging diet and exercise. Easy peasy.
 

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If you also do addiction fellowship, you could probably make a tidy living implanting probuphine and nexplanon in young addicts. Two for one special on Fridays!

I don't mind talking about metformin or checking the odd blood sugar, but modern diabetes care is complex and if you take responsibility for it, then you need to do it right, i.e. making sure they are getting checked for retinopathy, poking their feet with little fibers to look for neuropathy... it goes way beyond our training.
 

clausewitz2

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If you also do addiction fellowship, you could probably make a tidy living implanting probuphine and nexplanon in young addicts. Two for one special on Fridays!

I don't mind talking about metformin or checking the odd blood sugar, but modern diabetes care is complex and if you take responsibility for it, then you need to do it right, i.e. making sure they are getting checked for retinopathy, poking their feet with little fibers to look for neuropathy... it goes way beyond our training.
I realize you're mostly joking, but... how many psychiatrists are really set up with the sterile room you need from probuphine? It just seems like a terrible product from any kind of practical standpoint.
 

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So, when you walk into the room, the patient is not taking the medication, and when you walk out of the room, they either are taking the medication or some other solution to their problem has been devised? Do I understand correctly? If so please take a pause to accept:

Nobel Prize

(For which I regrettably do not have an emoticon!)
It's surprising to me that you are so sceptical about this. This is what we do. It's what we're good at. Did you get all the way through psych residency without learning any motivational interviewing?
 
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Since diabetes often can affect a person's mental state, can a psychiatrist treat diabetes? Or would they get into trouble with their boards since that technically is an endocrine issue?
I am a type 2 diabetes patient and infact, my doctor already worked with mental health professionals for my diabetic treatment. I had schizophrenia and therefore an increased risk of diabetes. But this risk was elevated by taking the psychotherapy treatment from a clinic in Toronto and helped me to keep the glucose levels near normal.
 
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Wilf

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It's surprising to me that you are so sceptical about this. This is what we do. It's what we're good at. Did you get all the way through psych residency without learning any motivational interviewing?
Shhh, we want to attract people to our field. One of my co-residents was lamenting one day about how in every other field of medicine MI means myocardial infarction but in our field it's motivational interviewing.
 

medhead1990

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oms-2 here so take it with a grain of salt.
To the OP- I say sure! As long as you feel comfortable doing it, I personally think its a great idea. I was recently at the AMP conference in Chicago (Association of Medicine and Psychiatry), and one of the things that they were talking about doing was pushing out some CME's to help psychiatrist feel comfortable managing the basics of HTN, diabetes and so forth.

The thought is that if you are seeing a pt. weekly or monthly than you are in a MUCH better position as a psychiatrist to help monitor those chronic diseases, than a FM/IM doc who sees them once every few months (ideally) or less. Technically according to the new lingo you are considered the primary care provider if you are seeing a pt. more often than any other provider. This follows the same logic that a OB/Gyn during a pregnancy becomes the primary care provider of that Pt.

A few of the members of the AMP group made a CME that was offered (I believe) at the APA conference for the last two years, which taught taking and monitoring BP's, and the basics of diabetes. They said the first year they had a good turn out and the second year the room was packed with people standing, so the OP is not alone in their interest. Within reason (as with all medicine) I think this is a great movement. My 2 cents would be take the CME and if at the end of it you feel comfortable doing the basics do them, in most every situation I can imagine (I am sure someone can find SOME example where this is not true) it will only increase quality pt. care.

For those interested, I believe the CME is put on by Erik Vanderlip MD MPH, and if I am remembering correctly there is now an online CME module as well through the APA website. Feel free to reach out if your interested or have questions.