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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?
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.
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?
Yes. You don't want to be on the other end of a plaintiff lawyer in this case.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
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.
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.
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.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.
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.
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.
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.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?
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.
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.
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!)
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?
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.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?