Carlat and Overzealous Psychiatrists

[kugel]

I have no plans to move back to N.J. at this time

Based on the 10 min of Jersey Shore that I've seen, the new 10% tax on tanning is going to force a lot of people to move out of NJ

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[kugel]

RANT ALERT! RANT ALERT!

I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease

"I think that practicing medicine is much more than simply writing out a prescription."

I completely agree. When I prescribe ANY medication, it is with an understanding of the current medical issues, medical history, family medical history. It is with an understanding of what medication categories are Likely to be prescribed to this patient In The Future 5-10 years. It is with an understanding of how the medicines I'm prescribing might interact with ALL of the above issues. It is also with an understanding of how/why the patient may have misused medications in the past and which ones are most likely to become a problem if the pt misuses the medications with a similar pattern in the future. It is also with an understanding of what medications will cause what problems in the case of accidental or intentional overdose. It is also with an understanding that I have a responsibility to educate the patient about all such matters, but in a manner that does not overwhelm him with information and details to the point that no message is received. It is also with an understanding that I will retain some responsibility for the outcomes, even if the patient misuses the medications I prescribed - for that is something of a failure of my education efforts.

That is why writing out a prescription (for ANYTHING) IS practicing medicine.

"Practicing medicine, to me, implies a comprehensive biological understanding of disease...."

If that is the case, then no one has ever "practiced medicine."
It is unfortunate for our patients that our understanding of the complexity of human behavior has not reached the level of biological detail as, say, streptococcal pharyngitis - but that does not mean we are not practicing medicine. Ever since ancients recognized a set of symptoms that fairly reliably went together (a syndrome) to produce a relatively predictable course (a prognosis), and recognized that some treatments typically produced better outcomes than others (a treatment plan), syndromic diagnosis and treatment have been the cornerstone of medicine for much longer than we have known specific causative agents.

And most of what I go to my Primary Care Physician for is syndromic diagnosis (viral URI, or ankle sprain, or even what what was very probably a single event of diverticulosis). That does not mean that I shouldn't accept the treatments (I do), but that syndromic diagnosis is STILL a huge part of medicine (even outside psychiatry).

And syndromic diagnosis and treatment, and understanding the risks & benefits of treatments, including the interactions with other current treatments and other likely future treatments, requires a fairly sophisticated understanding of the entire body in its current and future state. One that I did not come CLOSE to having after some 40 credits of courses (undergrad and grad) in psychology and 30 credits in biology (undergrad and grad). [Let's see, each semester was 12-14 weeks in the different schools I attended. So 70 credits means I had 70 hrs x 12 weeks = 840 classroom hrs. in psychology and biology before med school.) Med school was ~20 hrs per week in class x 44 weeks/year, or 880 classroom hrs per year; 1760 classroom hrs in first two yrs of med school.

My supervisors and attendings and deans knew that none of us were prepared to prescribe medications until we'd had another (avg. 50 hrs/week x 48 weeks per year x 2 years = ) 4800 hrs of Directly Supervised patient contact - AND passed a number of grueling nationally-standardized exams.

But yeah, I suppose you could say that it's not "practicing medicine" when we treat for Bipolar Disorder because we do not yet have a "comprehensive biological understanding of (the) disease."
I guess you could say that.
But that would mean that it's not "practicing medicine" when we treat for other illnesses for which we do not have a "comprehensive biological understanding of (the) disease":
Cluster Headaches
Diabetes
Backaches
ALS
Parkinsons Disease
Bells Palsy
AIDS
because we do not have a complete biological understanding of any of those.

My neighbor, the plumber, jokes that he has the same training as a cardiovascular surgeon because "it's all plumbing." Perhaps he's right.

 

[nancysinatra]

I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.

If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.

I tried to post this earlier but couldn't! Then Kugel beat me to the same basic point--with many good examples. So really I am just underscoring the same idea.

But here's my question... at one point you say or imply that psychiatrists should not prescribe antihypertensives or statins. Now in this post you are saying that what we do is fundamentally different from what other specialties do because we alone "do not have a fundamental biological understanding of what we are doing." Well then, can you explain the pathophysiology of essential hypertension? If what you say is true, then all non-psychiatric diseases must be well explained. Especially if they're outside our practice capabilities.

I would also add to Kugel's list much of rheumatology, including many autoimmune diseases. Can anyone explain lupus? In that realm they seem to meander through labs that sort of say this, but not quite that...

Your lobar PNA in an elderly woman case back before ABX resistance was such a problem (I'm only assuming, based on your story) is beautiful for how it illustrates a diagnosable disease with a known etiology proceeding to treatment (using PE, I hope! Please tell me you listened for egophany too!) However, come on, that's like the fairy tale version of internal medicine. Maybe in sports medicine, ortho and trauma surgery they get really clear cut stuff, but gosh, everywhere else it's a muck!

Anyone who has rotated recently through medicine knows, you do treat symptoms quite a bit. And then there is the all powerful prednisone, used to treat whatever comes its way.

 

[snarfer]

Great posts, Kugel and nancysinatra. I would add HTN, chronic pain, epilepsy, fever of unknown origin, autoimmune disorders, etc to your list. Many of my adult patients take 2-3 antihypertensives, prescribed by their PCPs, by the time they come to me for psychitric treatment. What is the biological etiology here? nobody really knows for sure. Is it renal insufficiency, decreased vascular compliance, obesity? Placebo can decrease BP in patients with HTN. Some patients respond with just diet and excercise. The list goes on and on. Other than common ailments such as bacterial infections, bone fractures, certain CVAs; comprehensive biological causes are not always known. Yet our colleagues in the the other specialties treat their patients and can call themselves medical doctors. We medical doctors-psychiatrists tend to be a bit hard on ourselves at times.

Interesting point regarding the PhD getting his NP license. I wonder why more LICSW, psyD, or PhD haven't pursued this route to gain prescription writing privileges. It adds 2-3 years of additional training and if these non-MDs feel prescerbing medicines would help their patient, given that we're too busy as is, I wonder why more haven't chosen this path. I wonder how much of this is economically driven. Many NPs/PAs/crna in the 1970s claimed their existence would ease burden on primary care. As it turns out, once they gained the rights to prescribe, many pursued more lucrative specialty fields instead of primary care.

therapist4change reference to how much psychotherapy is being taught in residency is an interesting one. I am obviously not familiar with all the residency training programs in the country. But in my area, all the residency programs teach at least one year of MET, CBT, IPT, CPT, psychodynamic, and even 3-4 months of DBT with video/live supervision. The one-two hour talks psychologists or social workers give to residents are usually just primers to the actual course. Residents can elect to learn more therapy in their fourth year. Many of my colleagues at conventions say their programs teach active therapy to their residents and fellows extensively as well. What I have found is that many patients really just do not like psychotherapy. they fine it cumbersome, expensive, and time consuming for them. It can also be difficult to separate therapy and medicine for many patients during our sessions, which can complicate treatment.

 

[kugel]

While therapy training in residency can vary, therapists training can also be a mixed bag in the community as pretty much anyone can do it. At times, I am appalled to learn what type of 'therapy' these non-MDs have been doing with my patients.

Although I agree with nearly everything Snarfer wrote (no big surprise, since it was in agreement with me), I want to caution against the argument that "since some in your profession do a less-than-perfect job, you have no place criticizing mine." That argument cuts both ways, and of course, "one bad apple don't spoil the whole bunch, girl."

This is about whether psychologists should be prescribing and esp. about Dr Carlat's posts on the subject, not whether (all) therapists do a good job. I'd just rather not go down that road.

 

[snarfer]

Although I agree with nearly everything Snarfer wrote (no big surprise, since it was in agreement with me), I want to caution against the argument that "since some in your profession do a less-than-perfect job, you have no place criticizing mine." That argument cuts both ways, and of course, "one bad apple don't spoil the whole bunch, girl."

.

Thanks Kugel. The last paragraph was in response to a post by therapist4change. No offense intended.

 

[kugel]

Thanks Kugel. The last paragraph was in response to a post by therapist4change. No offense intended.

Very clear it wasn't about me or anyone in particular. No offense taken.

 

[DrFrasierCrane]

Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.

 

[st2205]

Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.

Everyone gets really insecure about whether or not they're a "real doctor", alluding to the upmost important template of what a physician is that has been imposed by society. If you're not cutting open people's hearts, or prescribing dangerous combinations of drugs, or diagnosing the most obscure diseases all day and taking referrals from across the nation, then you're only half a physician, bordering on mid-level.

Most people are going to think you're a psychologist, or that you spend the day thinking about repressed memories.
Most people think opthalmologists are equivalent to optometrists.
PCPs do a job that can 'easily' be replaced by an NP.
Anesthesia isn't real medicine because it's as simple as knocking someone out. If it weren't so easy, nurses wouldn't be able to do it.
Derm is just a step up from the Clinique counter.
OB is overrated as many people are safely doing home-births these days. Many people with no medical expertise can deliver in an emergency situation with a little coaching from 911 over the phone.
Radiologists don't need medical school, as an MS or possible even a BS in anatomy and a wee-bit of clinical training could bring people up-to-speed in reading film and catching the necessary information from radiographs.
EM is really just cookbook medicine, the same as which is practiced by mid-levels at urgent cares. They're not involved with any long-term care of patients and do little more than stabilization. A monkey can stabilize.
IM, on the other hand, can treat long-term, but they can't stabilize for crap. Any doctor worth their weight in salt would be able to stabilize.
If you know the brachial plexus, you know neurology.

 

[kugel]

It is all plumbing. Plumbing also explains why I like being mean to people.

You're a Labrador puppy!
You can only "act mean" if we teach you to bark and snarl on command by making it into a game and then reward you with a rubber ball to chase.

 

[snarfer]

Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.

Don't give up on psychiatry, drfrasiercrane. I have been actively involved in a number of psychiatric research projects over the years and this is what I know. The reductionistic model in search for biological causes of psychiatric diseases have been unhelpful, which a lot of us have known for a number of years. It isn't in the serum or can be seen in morphometric neuroimaging studies. What has been encouraging of late is finding group differences in studies at various US and international labs how our brains communicate within itself amongst various psychiatric diseases. Biological predispositon and environmental factors play a huge role how our brains do this. While encouraging, the sample size in these studies had been small. What is being done within my very large research group (headed by colleagues as I am a part time researcher) and others is to recruit several hundred to 1000s subjects and controls for the next series of case control, longitudinal type studies. Prospective cohort studies are also needed but we all know how hard this can be to implement, if not impossible. Then if all goes well and the results are replicated, it will take more time for people on research task force to organize everything together and put it all together. Obviously this will take a number of years but the current data we have now is more encouraging that earlier ones with morphometric MRIs and serum plasma. And don't worry, we won't lose patients to the neurologists, PhDs/PsyDs/LICSWs . How we talk and treat patients is fairly unique in comparison to the other medical and non-medical specialties.

What I would caution you is to not let a few disenchanted individuals such as the Thomas Sasz and Peter Breggins of the world, both with minimal research material but are well spoken and well educated, influence your career decision. Both are famous and wealthy by writing books based largely on anectdotal evidence and self serving agenda.

 

[Doc Samson]

I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."

I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.

I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.

If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.

First off - welcome to the forum, glad to have you here.

In terms of your post - it would seem that no-one prior to the 20th century would fit your description of "practicing medicine." Since Galen, Hippocrates, Maimonides et al could not rely on independently verifiable data to support their diagnoses they were somehow invalid. I think we are "practicing medicine", it's just that the state of our art is far, far behind that of every other specialty. We will catch up eventually, and we will have a spectrum of genetic, neurotransmitter, and neuroimaging data to support (and perhaps even form) our diagnoses. I just don't think it'll happen while I'm practicing. I think our current practices will be looked back on just as our surgical colleagues look back on Civil War surgery - it's certainly nowhere near the modern standard of care, but it prompted great advances and lives were saved.

 

[Suedehead]

I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."

I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.

I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.

If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.
.

thought this was pure poetry

 

[worriedwell]

I think the challenge here is that fundamentally, people might be talking past each other if they are starting with different assumptions.

My impression is that Dr. Carlat views mental experience (and illness experience) as not reducible to a medical model.

That is, thoughts, fantasies, feelings, emotions, and difficulty regulating emotions, come from something not simply defined by our biology or even correctable/cured through influencing solely our biology.

Many Physicians who become Psychiatrists, start with the premise that medicalization will lead to the promise land to improve people's lives once we can understand things mechanistically. By doing that though, we have to use the analogy of physical medicine and assume that our mental experience is reducible. It is important to keep in mind that this is a theortical stance from which all of the other arguments about whether we are "practicing medicine" stems.

It is worthwhile wondering if it actually will be satisfying to define our mental and emotional experiences in a "medical" way.

One might argue, well its worth it to go down this path, because then we can really define the difference between "mourning and melancholia" with numbers and molecules, and then reassure those who are mourning that they don't have a "disease" and tell those with clinical depression they do have a disease that needs to be treated for x,y,z reasons.

But I can see how some might entirely reject that premise too, and maybe it is worthwhile being open to that.

 

[Daniel Carlat]

Though not the intention of his post, it is hard not to feel discouraged when reading Dr. Carlat's comments. As a medical student who has chosen psychiatry as his future field, a sliver of doubt is raised when a well-educated, well-spoken psychiatrist explains why I won't be a real doctor and will be effectively wasting my medical school education. So, that being said, I'd like to thank and applaud Kugel, Nancysinatra, and Snarfer for reminding me and other potential students who read these forums that psychiatrists are in fact medical doctors, too.

You're not wasting your education--far from it. As someone who has chosen psychiatry already you're in a good position, though I imagine you might be wondering how some of your rotations are relevant to your chosen field. When I was at UCSF, my residents knew I was the future psychiatrist and would often assign me to cases that involved heavy psychosocial components. I did plenty of extra reading etc....

But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot); adding a slew of new courses that are currently absent from or lightly covered in med school, such as Principles of Psychopharmacology, Medical Mimics of Psychiatric Disorders, Pharmacokinetics of Psychiatric Medications, The History and Clinical Use of DSM, Psychiatric Interviewing, Cognitive Behavioral Therapy, Practical Psychodynamics, etc....

I think all these didactics would fill about 3 years of this new Psychiatry Graduate Program, then all students would go into a two or three year psychiatric residency. The total training would last 5 to 6 years. The final degree: Psychiatric Physician, or Psychiatric Doctor, or Doctor of Mental Health, or other title.

If the American Psychiatric Association created and endorsed such a revision of training, obtaining the required legislation to ensure prescribing privileges and hospital admitting privileges would be a breeze, though would have to be done on a state-by-state basis.

If we started to plan this program now, we could enroll the first students within a couple of years, and the first graduates would start practicing in 2018 or so.

 

[Doc Samson]

Medical Mimics of Psychiatric Disorders.

You don't think you need the rest of medical school to understand this? I can't see very many successful CL psychiatrists being produced by a system that focuses on psychiatric education at the detriment of IM, surgery, OBGYN, neurology, etc.

 

[Daniel Carlat]

You don't think you need the rest of medical school to understand this? I can't see very many successful CL psychiatrists being produced by a system that focuses on psychiatric education at the detriment of IM, surgery, OBGYN, neurology, etc.

There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.

 

[Doc Samson]

There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.

I don't think I could disagree with you more. I'm not going to try and convince you otherwise because if Ned Cassem, George Murray, and Ted Stern couldn't convince you that we're doctors first and psychiatrists second, then I don't stand a chance.

 

[billypilgrim37]

I can't decide if the MGH fight or the puppy scolding is winning the thread...

 

[loveoforganic]

No more derailing! Awesome thread.

 

[kugel]

There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.

I happen to think psychologists are INCREDIBLY valuable to a C/L service, but if you read the info @ Henry Ford Hospital, the psychologists are part of a team including psychiatrists. There is no mention of psychologists operating independently as the THE consultant. Maybe it happens, but the link provided strongly implies otherwise.

 

[Faebinder]

You're not wasting your education--far from it. As someone who has chosen psychiatry already you're in a good position, though I imagine you might be wondering how some of your rotations are relevant to your chosen field. When I was at UCSF, my residents knew I was the future psychiatrist and would often assign me to cases that involved heavy psychosocial components. I did plenty of extra reading etc....

But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot); adding a slew of new courses that are currently absent from or lightly covered in med school, such as Principles of Psychopharmacology, Medical Mimics of Psychiatric Disorders, Pharmacokinetics of Psychiatric Medications, The History and Clinical Use of DSM, Psychiatric Interviewing, Cognitive Behavioral Therapy, Practical Psychodynamics, etc....

I think all these didactics would fill about 3 years of this new Psychiatry Graduate Program, then all students would go into a two or three year psychiatric residency. The total training would last 5 to 6 years. The final degree: Psychiatric Physician, or Psychiatric Doctor, or Doctor of Mental Health, or other title.

If the American Psychiatric Association created and endorsed such a revision of training, obtaining the required legislation to ensure prescribing privileges and hospital admitting privileges would be a breeze, though would have to be done on a state-by-state basis.

If we started to plan this program now, we could enroll the first students within a couple of years, and the first graduates would start practicing in 2018 or so.

Completely disagree. Yes follow the same concept of why an ophthomologist would go to medical school.

With this thinking, psychiatry will eventually evolve into psychology and as diseases become cleared genetically and are medically defined to an anatomical location or a physiologically defined mechanism, neurology would just take it over I suppose.

 

[Doc Samson]

I can't decide if the MGH fight or the puppy scolding is winning the thread...

Wouldn't call it an MGH fight, but the MGH CL experience is very illustrative of the need for physicians to be practicing psychiatry. Aside from the bread-and-butter stuff you see at any hospital, you also get a greater concentration of unusual cases. When a psychiatrist is called in because the internist/surgeon/neurologist is bewildered over what might be causing the pt's symptoms, you had better have a pretty broad medical knowledge to think of the zebras/unicorns that might be in play. Added to that, you are dealling with physicians from other specialties that certainly think they are at the pinnacle of their profession (and in some cases it's probably accurate) - if you're going to have a diagnostic disagreement with them (and chances are you will), you really do need that medical knowledge to explain why you believe they are wrong. Demedicalizing psychiatry would significantly damage the integration of our patients' medical care (which is already terrible - but we are making some strides). I have often used psychologists for testing on a CL service, and they are valuable - but I wouldn't want them opining on the differential of a delirium.

 

[Therapist4Chnge]

I have often used psychologists for testing on a CL service, and they are valuable - but I wouldn't want them opining on the differential of a delirium.

While not all psychologists would be suited to address complicating medical factors that may mimic psychiatric / cognitive conditions, a boarded neuropsychologist would be an asset in that setting. They could speak to how the patient's presentation and level of functioning is impacted, and back it up with objective data, and provide more information for differential dx.

 

[Doc Samson]

While not all psychologists would be suited to address complicating medical factors that may mimic psychiatric / cognitive conditions, a boarded neuropsychologist would be an asset in that setting. They could speak to how the patient's presentation and level of functioning is impacted, and back it up with objective data, and provide more information for differential dx.

An asset? Absolutely. Able to function in place of a subspecialty boarded CL doc? Absolutely not.

 

[billypilgrim37]

They could speak to how the patient's presentation and level of functioning is impacted, and back it up with objective data, and provide more information for differential dx.

If they're willing to do all of that for free, giddy up!

 

[TheWowEffect]

You're not wasting your education--far from it. As someone who has chosen psychiatry already you're in a good position, though I imagine you might be wondering how some of your rotations are relevant to your chosen field. When I was at UCSF, my residents knew I was the future psychiatrist and would often assign me to cases that involved heavy psychosocial components. I did plenty of extra reading etc....

But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot); adding a slew of new courses that are currently absent from or lightly covered in med school, such as Principles of Psychopharmacology, Medical Mimics of Psychiatric Disorders, Pharmacokinetics of Psychiatric Medications, The History and Clinical Use of DSM, Psychiatric Interviewing, Cognitive Behavioral Therapy, Practical Psychodynamics, etc....

I think all these didactics would fill about 3 years of this new Psychiatry Graduate Program, then all students would go into a two or three year psychiatric residency. The total training would last 5 to 6 years. The final degree: Psychiatric Physician, or Psychiatric Doctor, or Doctor of Mental Health, or other title.

If the American Psychiatric Association created and endorsed such a revision of training, obtaining the required legislation to ensure prescribing privileges and hospital admitting privileges would be a breeze, though would have to be done on a state-by-state basis.

If we started to plan this program now, we could enroll the first students within a couple of years, and the first graduates would start practicing in 2018 or so.

This is insane, to say the least.

I am sure you see patients with multiple medical issues, on multiple meds for these issues with complex psychiatric presentations. What makes you believe a training at a lesser level than a medical school will be adequate to take good care of these patients?

 

[Therapist4Chnge]

I am sure you see patients with multiple medical issues, on multiple meds for these issues with complex psychiatric presentations. What makes you believe a training at a lesser level than a medical school will be adequate to take good care of these patients?

The tens of thousands of NPs and PAs prescribing, and the already practicing prescribing psychologists?

 

[Faebinder]

The tens of thousands of NPs and PAs prescribing, and the already practicing prescribing psychologists?

They are inadequate as well and lucky for them, EMTALA at the ED is there to back them up (who knows for how much longer considering the mounting costs).

 

[Sneezing]

I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."

I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.

I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.

If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.

This is just plain silly. There are components of psychiatry that are firmly medical and have biological understanding of the disease process. Certain practice settings more so than others. But this is also today, the present, of psychiatry. Look back 50 years ago. How much was clearly understood then? And how much is understood now?

The future is coming, and it is coming fast. Psychiatry in the future, more than ever will necessitate that it be a medical field. You cannot make drastic changes of the field based upon what you see today. To regress to the dumbing down of being a psychological focus would only serve to stagnate the field in the face of the open frontier of emerging pathophys.

Imaging and genetics are going to merge. We will have clear delineations of the pathophysiology of mental illness. Who will you want to be interpreting these tests? I want a physician. But as you slander the heart of psychiatry and betray your own training, realize there are those of us going through the gauntlet now, who understand and see how being a physician is essential to the future diagnosis of mental illness.

Money will ultimately continue to drive this future. Mental illness has a very strong presence in the court system and with it high dollar issues. With the slightest emergence of medical imaging/genetic based diagnosis, there will instantly be acceptance by the courts. Government disability will also push this future, because they won't want to pay out to someone who really isn't disabled.

Advocating a merger for some new highbred practitioner is pointless. It already exists. It is called a psychiatrist. Your contention with the lack of therapy delivered is misdirected towards the specialty, and should be at the system that has shaped the emphasis upon med checks.

If there should be any training changes in mental health it should be a merger between MSW and PsyD. One is over trained.

I am quite pleased to have completed medical training and know the future of Psychiatric Medicine will be quite resilient to the onslaught of any psychological or midlevel wannabes.

 

[Ronpies]

Hi, Student Doctors--This is my first posting, and I am long past my student days! But I felt it important to comment on the controversy created by (among others), my friend and Tufts colleague, Dr. Daniel Carlat. I believe Dr. Carlat intended the issue of "prescribing privileges" for psychologists to serve as a kind of goad for the internal reformation of psychiatry; unfortunately, his seeming defense of the "medical psychologist" argument has created a good deal of dismay among many of us in the field of psychiatry. I hope you will take a look at the editorial I published on the psychiatrictimes.com website:

.http://www.psychiatrictimes.com/display/article/10168/1545667?CID=rss.


There, I argue that there is no such thing as "prescribing" apart from the practice of medicine; and that the practice of medicine requires a level of scientific knowledge that cannot be achieved through the proposed curriculum for "prescribing psychologists." The absence of systematic data on the practices of current "medical psychologists" is another huge problem, and this is not simply a matter of a "turf battle." It is a matter of defending the public safety, and insisting on scientific standards as the foundation for granting medical practice privileges.



For those of you going into psychiatry, don't despair! We have our internal problems as a medical speciality, to be sure--but we have always been and will always remain "real doctors", in the best and most comprehensive sense of that term: treating the "whole person" by integrating biological, psychological, social, and cultural knowledge into a coherent framework of care.



--Best regards, Ronald Pies MD

 

[TheWowEffect]

Hi, Student Doctors--This is my first posting, and I am long past my student days! But I felt it important to comment on the controversy created by (among others), my friend and Tufts colleague, Dr. Daniel Carlat. I believe Dr. Carlat intended the issue of "prescribing privileges" for psychologists to serve as a kind of goad for the internal reformation of psychiatry; unfortunately, his seeming defense of the "medical psychologist" argument has created a good deal of dismay among many of us in the field of psychiatry. I hope you will take a look at the editorial I published on the psychiatrictimes.com website:

.http://www.psychiatrictimes.com/display/article/10168/1545667?CID=rss.


There, I argue that there is no such thing as "prescribing" apart from the practice of medicine; and that the practice of medicine requires a level of scientific knowledge that cannot be achieved through the proposed curriculum for "prescribing psychologists." The absence of systematic data on the practices of current "medical psychologists" is another huge problem, and this is not simply a matter of a "turf battle." It is a matter of defending the public safety, and insisting on scientific standards as the foundation for granting medical practice privileges.



For those of you going into psychiatry, don't despair! We have our internal problems as a medical speciality, to be sure--but we have always been and will always remain "real doctors", in the best and most comprehensive sense of that term: treating the "whole person" by integrating biological, psychological, social, and cultural knowledge into a coherent framework of care.



--Best regards, Ronald Pies MD

Thanks for the response, Dr. Pies. I believe Dr. Carlat should look elsewhere for fame and controversy.

Hiding personal agenda/ambition under the guise of reforming the field is highly unethical.

 

[billypilgrim37]

I think we should all remember that, despite the utter absurdity of his stance on this issue, Carlat's writings otherwise are some of the most important and accessible things produced outside of journals. He's made it cool to hate pharma influence, and generally, he writes with intellectual rigor and honesty. The Carlat Report, and his blog (where he gives us a bit of a shout-out, btw), are incredibly worthwhile.

He also runs the risk of becoming the Ralph Nader of psychiatry.

 

[nancysinatra]

But it is true that much of the med school curriculum is overkill for psychiatry, which is why I hope that we can put our heads together and create a hybrid of medical school, psychology training, and psychiatry residency. This would involve harvesting the most relevant of the medical school didactic courses and tweaking them to make them more useful to future psychiatrists; getting rid of courses that just aren't at all relevant (I would put gross anatomy, histology, pathology in that pot)

This means psychiatrists should not longer treat dementia. It also will reduce opportunities for neuropsych fellowships. Alzheimer's and other dementia diagnoses are made definitively on autopsy, by pathology. Going to medical school and knowing something about histology and pathology is relevant to these diseases.

I personally found even my surgery clerkship (a clerkship I believe you mentioned earlier as not being relevant) useful--I did a month of bariatric surgery which has a lot of psych overlap. I also did trauma surgery as an elective. The overlap between that population and ours is also impressive. Sometimes the usefulness is what you personally put into your studies.

 

[Doc Samson]

I think we should all remember that, despite the utter absurdity of his stance on this issue, Carlat's writings otherwise are some of the most important and accessible things produced outside of journals. He's made it cool to hate pharma influence, and generally, he writes with intellectual rigor and honesty. The Carlat Report, and his blog (where he gives us a bit of a shout-out, btw), are incredibly worthwhile.

He also runs the risk of becoming the Ralph Nader of psychiatry.

He's also got the cojones to post under his real name, so let's argue the issue at hand rather than casting aspersions on his motivations.

 

[nancysinatra]

He's also got the cojones to post under his real name, so let's argue the issue at hand rather than casting aspersions on his motivations.

I agree with that. Also it is nice to see an interesting debate about psychiatry occurring here.

 

[jettavr6]

Beyond that, in outpatient settings, practices vary widely. Some "go-getter" psychiatrists see themselves as primary care doctors, and check blood pressures, check lipid levels aggressively and institute statin treatment. Unless the psychiatrist is double-boarded in medicine and psych, I find this practice worrisome. Medicine is getting more and more complicated and I would not want my child being treated medically by a psychiatrist.

In fact, I find it particularly worrisome that more psychiatrists aren't treating the basic medical conditions (yes, like it or not, we are MD's) that our patients have. Many of these basic conditions ie, diabetes, htn are caused by the medications we prescribe and it sometimes takes weeks if not months for patients to be seen by their primary care physicians. Meanwhile, we sit back and absolve ourselves of any responsibility that doesn't deal exclusively with mental health.

I applaud those psychiatrists who use their medical knowledge to initiate basic medical treatment while the patient is waiting for an appointment with their pcp. Let me emphasize that basic treatment includes very few conditions and each physician should not venture any farther than their know how. Equally, I applaud those PCP's who start a patient on a psychotropic (even if it's the wrong one) while the patient is waiting to be seen by us.

Carlat.......why shouldn't a psychiatrist or "go getter" as you describe, continue to hone and maintain their medical knowledge? Medicine may be getting more complicated, but the basics still apply.

 

[nancysinatra]

Wasn't it not that long ago that a "general practitioner" was someone with one year of internship who worked in a family-type practice and did almost everything? I realize medicine is much more complicated and regulated now, but not all aspects are equally more complicated. I don't think being boarded in IM is necessary to start a HTN medication, even nowadays. Of course there is a limit where you have to refer the patient or call a consult.

Plus if you restrict what "psychiatrists" do to only "mental health" and really want to limit it, then what about when we use medications like beta blockers for anxiety? Are we practicing "medicine" or "psychiatry?" If a medication is used off label that comes from, say, neurology, but it works, for, say, depression, well, what about that situation? (If I didn't go to medical school, but had only studied "psychopharmacology"--I sure wouldn't feel right using it then!) If I admit an inpatient who's on a bunch of cardiac medications, am I "practicing medicine" because I start all his heart medications? Do you expect me to call cardiology? Personally I think that would be ridiculous. And I would have numerous more similar questions.

And patients may bring medical matters to a psychiatrist's attention. If the psychiatrist is not knowledgeable, they may fail to make the correct referral.

 

[billypilgrim37]

It'd be fair to point out that for many of the most medical objections we have, DC has admitted that the "neuropsychiatrist" would be the most appropriate care giver. He's not saying that no psychiatrists should go to medical school, just the vast majority of outpatient ones shouldn't.

I think we all still vehemently disagree with this, but it is a different (and less unreasonable) point.

 

[OldPsychDoc]

I think we should all remember that, despite the utter absurdity of his stance on this issue, Carlat's writings otherwise are some of the most important and accessible things produced outside of journals. He's made it cool to hate pharma influence, and generally, he writes with intellectual rigor and honesty. The Carlat Report, and his blog (where he gives us a bit of a shout-out, btw), are incredibly worthwhile.

He also runs the risk of becoming the Ralph Nader of psychiatry.

He might well consider that a compliment!

 

[Therapist4Chnge]

He might well consider that a compliment!

The Status Quo for many is viewed negatively, so in that sense it would be seen as quite complementary.

I am curious when psychiatry started to move away from doing physicials. I am sure some psychiatrists still do them, though it seems it has been relegated to mid-level staff and/or extenders. It seems that this change was an unintended consequence of shifting the value of psychiatry from medical knowledge with pharmacology to primary prescribers and mid-level supervisors. I've been thankful to work with psychiatrists who did more than write prescriptions, though the downward pressure from hospitals/insurance companies seems to necessitate farming out everything that is not prescribing or committing.

The fight shouldn't be with other physicians (neurology), other doctoral level clinicians (psychologists, optometrists, etc), but with the healthcare system. While there needs to be a more comprehensive answer to what is required to ethically and adequately prescribe, I think the overarching shift of psychiatry is the larger issue....which is why Dr. Carlat's post was so timely.

 

[TheWowEffect]

Wasn't it not that long ago that a "general practitioner" was someone with one year of internship who worked in a family-type practice and did almost everything? I realize medicine is much more complicated and regulated now, but not all aspects are equally more complicated. I don't think being boarded in IM is necessary to start a HTN medication, even nowadays. Of course there is a limit where you have to refer the patient or call a consult.

Plus if you restrict what "psychiatrists" do to only "mental health" and really want to limit it, then what about when we use medications like beta blockers for anxiety? Are we practicing "medicine" or "psychiatry?" If a medication is used off label that comes from, say, neurology, but it works, for, say, depression, well, what about that situation? (If I didn't go to medical school, but had only studied "psychopharmacology"--I sure wouldn't feel right using it then!) If I admit an inpatient who's on a bunch of cardiac medications, am I "practicing medicine" because I start all his heart medications? Do you expect me to call cardiology? Personally I think that would be ridiculous. And I would have numerous more similar questions.

And patients may bring medical matters to a psychiatrist's attention. If the psychiatrist is not knowledgeable, they may fail to make the correct referral.

Great response, To build on it a little bit- how about when discharging patients. We write all kinds of medications to take home. I usually don't see a point calling a medicine guy for patients with simple UTIs, HTN, uncomplicated DM, cholesterol etc. How about when a patient comes with late onset psychosis? There are just numerous examples like this.

There is something to said about "legitimate concerns" v/s "unnecessary provocations". That calls for addressing motivations behind such acts.

 

[Gooner007]

I totally agree that my argument sounds silly at face value. But I'm driving at an issue that (I think) is a profound problem for psychiatry. One of the arguments I commonly hear against psychologists prescribing, or in favor of the idea that medical school is essential for prescribing, is some variation of: "writing out a prescription is, in fact, practicing medicine."

I disagree, because I think that practicing medicine is much more than simply writing out a prescription. Practicing medicine, to me, implies a comprehensive biological understanding of disease, and a series of technical procedures and decisions based on that understanding. Thus, when I did my medical internship at St. Mary's hospital in San Francisco, I really practiced medicine. For example, I remember admitted many elderly women with pneumonia. I listened to their lungs for crackling, I ordered chest X-rays to look for signs of lobar pneumonia, I ordered blood tests to look for elevated WBCs, I got blood cultures to decide which antibiotic was most appropriate, and then I prescribed a drug based on that medical work.

I maintain that psychiatry as we now practice it it fundamentally different from medicine. Unlike every other specialty, we do not have a fundamental biological understanding of what we are doing. Instead, we rely on a psychological understanding. That is, diagnosis proceeds exclusively based on a series of psychological procedures, including interviewing, observing behavior, and making judgments about how behavior and responses to questions relate to the array of diagnoses available to us in the DSM. Sure, we order labs and sometimes MRIs, but this is all in order to rule out a medical condition, and not to diagnose a psychiatric condition.

If we heal without a biological understanding of what we are healing, we are certainly healers, but can we really call ourselves medical doctors in the way that other specialists can? I wonder.

I'm a fourth year medical student, currently rotating through all the specialties...so I hope I'm not being too naive!

I find that your idea of practicing medicine is only a small part of the equation. The practice of medicine is not only treating the specific disease of patients, but also of increasing the quality of our patients lives. So it also includes Social, Occupational, and overall functioning beyond the disease.

In my experience so far, Psychiatry is aimed at increasing the quality of patients lives in a more comprehensive way than other specialties. I would argue that other specialties focus too much on disease which is only one part of what the practice of medicine is about.

Can other specialists really call themselves medical doctors in the way psychiatrists can?

 

[Anasazi23]

There are actually many excellent psychologists who work on consult-liaison services. See, for example, the training for psychologists at the Henry Ford Hospital. No, I do not accept the notion that one needs to go through clinical rotations in these fields in order to treat the psychiatric problems of patients with medical illness.

This statement just seems impossible for me to believe - particularly coming from someone well-versed in the complexities of psychopharmacology.

I could write pages as to why a psychiatrist is, as DS pointed out, a physician first, and psychiatrist second. In sum though, there is more than just something to be said for a physician's arm-length "eyeball" of a patient that's not sat well with a psychiatrist, made a referral or ER admission, and resulted in a saved life. All this, and I still feel that there is worlds to know about the interface of psychiatric disease and that of traditional medicine.

To assert that a psychologist could accomplish the same with none of the same formalized training is flabbergasting to me. The medical clinical accumen simply is not there. How could it be? Certainly not through non-residency based weekend pseudo-rotations not reviewed by seasoned attendings.

 

[loveoforganic]

Anasazi - could you clarify your rationale for distinguishing between physicians and psychiatrists?

"a physician first, and psychiatrist second"

 

[Gooner007]

Anasazi - could you clarify your rationale for distinguishing between physicians and psychiatrists?

"a physician first, and psychiatrist second"

Probably something to do with the 4 years of Medical School, prior to specializing in Psychiatry later? I completely agree with his statement.

Personally, I would never be interested to enter psychiatry without education in other fields of medicine. I would not feel competent enough to care for patients.

I respectfully disagree with Dr. Carlet on many levels.

For instance, eliminating traditional medical school curriculum would further add to stigma that mental illness is different from other diseases.

Patients do not get adequate treatment outside of their mental illness. Internal Med physicians will not care for patients mental illness complaints. And conversely, psychologists aren't trained to look for patients somatic complaints.

Psychiatrist are essential in filling that gap. And its the years of medical school and residency training which allows them to do so.

 

[Therapist4Chnge]

Anasazi - could you clarify your rationale for distinguishing between physicians and psychiatrists?

"a physician first, and psychiatrist second"

This is a common differentiation, particularly when discussing the differences between psychiatry and psychology. In psychiatry you are first a physician and then you train as a psychiatrist. In psychology you are a scientist first and then you train as a psychologist.

 

[st2205]

I think you mean the mind, rather than the brain. Though psychologists have their required neuro anatomy or behavioral neurobiology, they are not neuroscientists (clinical psychologists, that is, excluding neuropsychologists).

 

[Therapist4Chnge]

Psychologists also focus on the study of the brain very comprehensively and not only pathologies am I correct? Psychiatrists seem to be there to help mental health issues, mostly.

Maybe I'm wrong. I'm an ignoramus dog.

Some psychologists (neuropsychologists and rehabilitation psychologists w/ a neuro focus) have a firm grasp on neuroanatomy, neurophysiology, etc....though the average psychologist does not. This is actually one of my biggest pet peeves about psychology. I'd most trust boarded neuropsychologists and neuro-focused researchers, but that is just my opinion.

As for the role of psychiatrists, I'll leave that up to the other posters.

 

[loveoforganic]

This is a common differentiation, particularly when discussing the differences between psychiatry and psychology. In psychiatry you are first a physician and then you train as a psychiatrist. In psychology you are a scientist first and then you train as a psychologist.

I don't see the power of the distinction though, when different terms (psychiatrist/psychologist) are used as the end. Is the statement essentially saying "physician/scientist first, fixer of the mind second? I couldn't think of a better term to encompass both.

Also, I've heard similar statements before, all referring to psychiatry - there are no common parallel statements for other fields of medicine, are there?