Carlat and Overzealous Psychiatrists

[sunlioness]

It certainly makes since that this is true and we all assume that psychologists would have better outcomes performing psychotherapy compared to psychiatrists or LCSW's. However, does anyone know if any studies have looked at this directly? I can say that some of the best therapists I know are LCSW's.

Agreed. Actually most of the best therapists I know are LCSWs. I'm not all that impressed with LPCs though (though of course I do know some good ones as well), I have to say. Of course, none of this is at all scientific and I know some great psychologists.

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[dl2dp2]

I'm not sure if this RxP thing is actually at all good for psychologists. It seems to me that a doctoral psychologist is not the same as an NP/PA. They are independent practitioners and positioned at the same level as a psychiatrist. However, the RxP movement changes this dynamic. Remember psychologists do NOT need any physician supervision for psychotherapy. Presumably even RxPs can't prescribe without at least some degree of physician (at least PCP) supervision, which would subjugate RxPs to a loss of autonomy, and make a doctoral level psychotherapy practitioner even less respectable as it is already.

Although, I suppose in the current climate when NP/PAs sometimes get paid substantially more than PhD psychologists, losing a bit of that autonomy and "status" may be justified monetarily.

But yes, I think if psychologists are willing to become psych NP/PAs, it'll only be a good thing for psychiatrists.

Regarding psychiatrists doing psychotherapy--there is a weird paradox. Even though supposedly psychologists do better therapy, they often get paid less doing it. Secondly, most of the psychoanalytic candidates are MDs. Thirdly, cash-only therapy practices are much more difficult to sustain for a psychologist than a psychiatrist. Evidence-wise, I BET you a randomized controlled study, if done, will show that LCSW/MD/PhD/PsyD all have roughly equivalent efficacy on average. I think thus far we have not discovered methodologies in psychotherapy that would significantly enhance or even normalize response rates across populations.

I'm not sure what this means, just pointing out some phenomenology.

 

[Evidence Based]

Evidence-wise, I BET you a randomized controlled study, if done, will show that LCSW/MD/PhD/PsyD all have roughly equivalent efficacy on average.

This is one of those things that I feel like shouldn't be true, but I believe it is. I don't believe there have been any studies that have shown differential outcomes in therapy cases across providers. I can specifically remember one study off the top of my head, coming from Penn, that showed no difference in outcomes between community LICSWs and university based psychologists in implementing flooding for PTSD. The citation escapes me at this point (I feel like it was a review article by Edna Foa?) but this is probably not the only article in this vein.

This is rather annoying for psychologists, who have gone through at least 5 or 6 years of training only to be told they do no better than a social worker with a 2 year degree. I feel like something doesn't compute here, so if someone knows any better please correct me. But from what I've read, this is where the data stand now.

 

[sunlioness]

Well, psychologists still have the market cornered on neuropsych testing. No one else does that and they're darned good at it.

 

[AleksPsych]

This is one of those things that I feel like shouldn't be true, but I believe it is. I don't believe there have been any studies that have shown differential outcomes in therapy cases across providers. I can specifically remember one study off the top of my head, coming from Penn, that showed no difference in outcomes between community LICSWs and university based psychologists in implementing flooding for PTSD. The citation escapes me at this point (I feel like it was a review article by Edna Foa?) but this is probably not the only article in this vein.

This is rather annoying for psychologists, who have gone through at least 5 or 6 years of training only to be told they do no better than a social worker with a 2 year degree. I feel like something doesn't compute here, so if someone knows any better please correct me. But from what I've read, this is where the data stand now.

I do not have references to list, but I know they exist... There are many studies that show that manual-based psychotherapies (e.g., CBT for PTSD) can be provided at an equal level of efficacy by social workers and psychologists. This is true only when clinicians adhere strictly to the protocol of the therapy. However, there are also some studies that show that when clinicians practice non-manualized therapies or have to deviate from the manual those with better training and more experience have better results.

 

[Therapist4Chnge]

In fact, no self respecting psychiatrists or primary care doctors would ever make the claim that they can do psychotherapy or perform neuropsychological testing as well or better than PhDs/PsyD with our 1-3 years of training (at least in psychiatry traning, not IM or FP or peds). To the best of my knowledge, no MDs/DOs have lobbied to obtain the right to perform neuropsychological testings, although it can take months to have anyone tested in my area, because we know we won't do as a good a job as our colleagues in psychology. Interestingly, LICSWs can do psychotherapy with just 1-2 years of training.

I have definitely seen psychiatrists claim they can do psychotherapy as well or better than a psychologist. As for neuro testing, your colleagues in neurology often take stabs at interpreting neuropsychological assessments. There is a push in some circles to get standardized computer reports, which is a very slippery slope.

 

[Ronpies]

from Ron Pies MD

.Earlier tonight, I learned that Oregon Governor Kulongoski has vetoed the bill that would have allowed psychologists to practice clinical medicine without adequate training, otherwise known by the euphemism of "prescribing". The Governor's rationale was precisely the one opponents of the bill, such as myself, had advocated. As the Oregonian newspaper [..http://www.oregonlive.com/politics/..
index.ssf/2010/04/kulongoski_vetoes_bills_on_pre.html] put it: .
."Medical groups and even some psychologists opposed the bill. [Governor] Kulongoski said such a change "requires more safeguards, further study and greater public input." .

.That is an understatement! And, contrary to an oft-repeated claim that the Oregon bill required prescribing psychologists to obtain a medical assessment by the patient's “medical doctor", the bill required only "collaboration" with the patient's "health care professional". There was nothing in the bill that stipulated that this "professional" be a medical doctor.
.
.Furthermore, the perverse notion that it is the job of physicians to demonstrate that psychologists have actually "caused harm" before opposing their unsupervised prescribing of medication turns science in the public interest on its head. It is the responsibility of those who claim the prerogatives of the physician to demonstrate to the general public, and to the scientific community, that their methods and practices have been proved safe and effective.
.
.There is not a scintilla of credible, scientific evidence showing that "prescribing psychologists" in New Mexico or Louisiana have practiced safe and effective prescribing--though I suspect many have done so, and that most are careful and conscientious clinicians. There has been, to my knowledge, no systematic monitoring or objective analysis of these psychologists' practice patterns. The mere absence of reports (of adverse drug reactions) does not constitute "credible, scientific evidence." Nor are the data furnished by the Department of Defense project--which involved ten psychologist prescribers, closely supervised by psychiatrists--applicable to the psychologists prescribing in New Mexico and Louisiana.
.
.Imagine if this sort of Orwellian logic were applied by a drug company to its newly-released medication: "Well, we don't have any adverse reports coming in, so our drug must be pretty darn safe!". Has it occurred to those who believe we have good "safety data" on psychologist prescribers that there is an inherent conflict of interest among psychologists and their collaborating physicians, with respect to reporting an adverse drug reaction? Does the term "malpractice suit" ring any bells?
.
.All this said, psychiatrists and primary care practitioners need to get their own houses in order. We are far from unblemished in our own prescribing practices, as I have observed after 28 years in the profession. We need to ensure that prescribing on the part of PCPs and psychiatrists is undertaken only after thorough assessment of the patient; consideration of non-pharmacological options (e.g., "talk therapy"); a careful "risk-benefit" discussion with the patient--and after having mastered the relevant literature on psychopharmacology. To be sure, we have a long way to go--but the solution is better training and education for physicians, not the creation of new classes of "prescribers" who lack comprehensive medical training.
.
.We also need to find ways to address the crushing shortage of qualified physicians—both general and psychiatric—in under-served areas of the country. For example, we could consider national legislation that would subsidize medical education for those who agreed to practice either primary care or psychiatric medicine, in under-served regions. We could also offer incentives to primary care doctors for undertaking specialized training in psychopharmacology, under the tutelage of experts in the field.
.
.Finally, we physicians need to educate the public and our legislative representatives on why "prescribing" cannot be separated from the art and science of medical care. To advocate such a separation is to dissect muscle from bone, using a paring knife: it can't be done without injuring the patient.
.


Ronald Pies MD
Professor of Psychiatry,
SUNY Upstate Medical University, Syracuse NY;
and Tufts USM, Boston

 

[maranatha]

I have definitely seen psychiatrists claim they can do psychotherapy as well or better than a psychologist. As for neuro testing, your colleagues in neurology often take stabs at interpreting neuropsychological assessments. There is a push in some circles to get standardized computer reports, which is a very slippery slope.

And that isn't possible? Without seeing any studies, I'd say that in general psychologists are the best at what they do, psychotherapy. (However, I'd like to see the studies). Clearly they have the most training and that is their domain. However, there are some damn good psychiatrists and LCSWs doing therapy and I'm comfortable saying that I doubt there is any differences in outcomes between the good psychiatrists and LCSWs vs. a psychologist. Our residents are trained with many of the same methods, books, and clinical instructors in CBT and IPT. Again, I'm not at all or in any way saying that makes us equivalent (so as not to create a thunder storm--I can just see edieb or some of others on psychology forum turning red in the face), but for those of us who are motivated to learn, we get pretty good training.

 

[whopper]

However, does anyone know if any studies have looked at this directly? I can say that some of the best therapists I know are LCSW's.

It depends.

In studies, psychotherapy to treat depression, well heck, it didn't matter the level of training of the psychotherapist. According to a grand rounds I attended, even a volunteer, just simply talking to someone on a consistent basis provided more benefits vs. someone with years of experience.

That, however, is the extent as far as I'm aware where training actually does not make a difference. I haven't looked upon the data for some time because I'm more focused on a forensic curriculum as of this moment, but depending on the other types of psychotherapy, from what I understand, training can make a difference.

And I can certainly say from just my own personal experience, you really can't understand several forms of psychotherapy unless you have some training in it. You can't throw someone to a patient and expect that person to perform DBT or CBT if that person doesn't know how it works.

I can say that some of the best therapists I know are LCSW's.

I think we can all agree that some people, despite having the best or worst grades, training, etc, can end up being clinicians of a sort where their clinical skill did not have much correlation with their training.

I've noticed some people, the more educated they are, the more cold, analytical, and socially-detached they become. Psychotherapy is also a type of treatment where there will be a lot of variability between therapists, even if employing the same psychotherapeutic techniques.

 

[whopper]

http://www.oregonlive.com/politics/index.ssf/2010/04/kulongoski_vetoes_bills_on_pre.html

I put this link because Dr. Pies post was for the Oregonlive, but not the specific article.

I agree with Dr. Pies's statements.

I am very frustrated with the level of animus and emotionalism that surrounded this bill. Many of the arguments were not based on studies, but merely talking points to the effect of "this is safe, it was studied by the department of defense."

Anyone who actually read the study would know that it did not conclude that psychologist prescription power was a safe practice, nor did it recommend it's results were generalizable to the community.


To allow psychologists to prescribe without some adequate data, well that's just putting patients on the experimentation chopping-block. If there is good data to demonstrate it's safe, well then hey, show it to us! I've yet to see anyone do that, and anytime I asked, I keep getting referred to the DOD study which as I said time and time again did not answer the question.

In any case, apparently from the above data, the bill was vetoed. Here are my suggestions:
1) We psychiatrists need to work with those in Oregon, actually any state where there is a shortage of doctors to prescribe
2) Doctors in Oregon should be collaborating with psychologists.
3) If psychologists want to prescribe, other than going the more traditional routes, my suggestion is to do a study where psychologists prescribed, gather the data, and the methods have to strongly correlate with the powers psychologists will get in the bill.

If you are going to allow a psychologist to prescribe without data to back the safety of the practice, then you are experimenting on patients.

 

[whopper]

http://www.psychologytoday.com/blog...prescription-privileges-conversation-part-one

Saw this article while I was looking for the specific article Dr. Pies mentioned.

Ouch, I hate writing this because based on Dr. Carlat's other work, I respect what he does.

I found the article, ahem, cough, cough, misleading.

We are not in a day and age where psychiatric medications do not cause side effects that can seriously affect someone's health.

The need for someone to understand the body, on the level of that of a medical doctor, in the practice of prescribing psychotropic medications, and has the final say is still needed.

"But why would a psychiatrist have to learn all those things? You don't do physical exams or surgery, do you?"

"No I don't. And almost none of my colleagues do either. Mostly what we do is what I am doing right now-sit across from people and talk to them. And at the end of the conversation, I usually write out a prescription."

Almost none? I know a lot that do. Physical exams are still very much needed in several scenarios.

I don't know if you will respond to this Dr. Carlat, but I really believe you are very much under-playing the role of the medical model in psychiatric practice.

I certainly hope you are following ADA guidelines when prescribing an antipsychotic...
http://www.zyprexa.com/mm/zyprexahcpcharts/images/stchart.gif

 

[Doc Samson]

Maybe psychiatrists that have private practices that require the presence of a Queen Anne chair don't have much use for their medical training, but come work a shift in my ED or consult to one of the 12 subspecialty ICUs my team covers and we'll see how much of your general medical knowledge and physical exam skills your patients can afford for you to lose.

 

[snarfer]

http://www.psychologytoday.com/blog...prescription-privileges-conversation-part-one

Saw this article while I was looking for the specific article Dr. Pies mentioned.

I found the article, ahem, cough, cough, misleading.

We are not in a day and age where psychiatric medications do not cause side effects that can seriously affect someone's health.

The need for someone to understand the body, on the level of that of a medical doctor, in the practice of prescribing psychotropic medications, and has the final say is still needed.

Almost none? I know a lot that do. Physical exams are still very much needed in several scenarios.

I certainly hope you are following ADA guidelines when prescribing an antipsychotic...
http://www.zyprexa.com/mm/zyprexahcpcharts/images/stchart.gif

If I was a patient of one of these MDs Daniel Carlat says he knows, I would be very worried for my safety. Especially if I am taking Venlafaxine or Risperidsone and no body has measured my BP, pulse, waist circuference, weight, and ordered or followup with my ekg, fasting lipids/glucose/insulin. The PCPs have too much on their plates to do any of these. This is why they referred these patients to us MDs! Maybe you can use an RN to get the VS but that would be way overkill.

His comments are obviously misleading and not representative of what real psychiatrists do.

I wonder what his true motivations are. In my group practice, the medical/psychiatry training I had have been priceless.

 

[whopper]

Maybe psychiatrists that have private practices that require the presence of a Queen Anne chair don't have much use for their medical training, but come work a shift in my ED or consult to one of the 12 subspecialty ICUs my team covers and we'll see how much of your general medical knowledge and physical exam skills your patients can afford for you to lose.

This was brought to Carlat's attention in the forum, and he said he is very aware of how psychiatry differs in scenarios other than the outpatient, yet he was still of the same opinion.

The only type of scenario I can think of that fits Carlat's mentioning is an outpatient setting where one only sees patients with disorders that require much more psychosocial intervention than pharmacologic, do not have complicating medical problems, only require low dosages of medications, and none of the psychotropics given out are mood stabilizers, antipsychotics, or B-blockers. Even then, a medical issue can come up from time to time. That certainly is only a small part of the spectrum of our field.

 

[Doc Samson]

Dr. Carlat has perhaps made the error of fighting a war on two fronts.

Act I: He (reasonably and thankfully) "went after" all the docs who shill for big pharma (and those who use big pharma as their sole source of CME).

Act II: He has alienated all psychiatrists who believe that medical training is essential to what we do - by far and away the majority of the audience he cultivated in Act I.

Now his remaining audience will consist of who? Psychologists and laymen with a bone to pick with organized psychiatry. It's really a shame because he WAS a figurehead for a more ethical and transparent approach to psychopharmacology. Amongst his colleagues he has lost his soapbox.

 

[whopper]

From all his posts, I think his interpretation of psychiatry is different than most here on the forum. Our medical skills, in addition to our psychotherapeutic skills should be cultivated.

I'm actually a bit, well dumbfounded. I have an old issue of the Carlat report where the theme of the article is to remember the liver interactions with the various psychotropic medications. I figured someone behind that type of publication would certainly know that the medical model is very important, yet the Carlat I'm seeing from the posts and the above article from Psychology Today appears to be of a very different sort.

 

[nancysinatra]

Do people even talk like that with their patients? No one speaks in full formed paragraphs like that!

Anyway I think he demonstrated a serious boundary violation in that article--using his patient's appointment time to try to indoctrinate her with his curmudgeonly attitudes about the medical profession. I hope the story's not true.

Whatever... any impressionable youngsters who read this thread from the beginning are going to have the impression that:

a) psychiatrists do not need or use medicine

b) psychiatrists are also bad at therapy

Which means that that psychiatrists do what, exactly?

That's right:

http://ecx.images-amazon.com/images/I/31E686YHDKL._SL500_AA300_.jpg

 

[HMSPSYCH]

Do people even talk like that with their patients? No one speaks in full formed paragraphs like that!

Anyway I think he demonstrated a serious boundary violation in that article--using his patient's appointment time to try to indoctrinate her with his curmudgeonly attitudes about the medical profession. I hope the story's not true.

Whatever... any impressionable youngsters who read this thread from the beginning are going to have the impression that:

a) psychiatrists do not need or use medicine

b) psychiatrists are also bad at therapy

Which means that that psychiatrists do what, exactly?

That's right:

http://ecx.images-amazon.com/images/I/31E686YHDKL._SL500_AA300_.jpg

I often wonder about the mental health of seasoned attending psychiatrists after so many years of treating patients. My $.02 is that many of us enter the profession not any more neurotic than the other
medical specialties but some of us literally loose it after 10-20 years.

Like warren buffet said 'it takes 20 years to build one's reputation but only 5 minutes to tear it down'.

 

[Sneezing]

I made a similar post in the celebration thread of the veto of the Oregon bill.

There are two main arguments fueling this crockery.
1) shortage of psychiatry
2) Underserved areas

I believe and propose the best solution for both of these is utilization of telepsychiatry. Primary care docs are often the ones who have first exposure to many of our patients. They don't always get things right. As a result their pysch patients keep coming back more and more. With telepysch we can put cameras and monitors up in their office to more readily consult with them directly. Either by seeing their patients or providing curbsides. By improving their rate of diagnosis and treatment, it allows a greater reach to more patients.

We can still live in more desirable areas by using telepsychiatry to reach out to the underserved areas. I propose that the program directors on this site contemplate integrating telepsych as a requirement into their residency programs to better equip us for the future. Spread the word. Get this to be mainstream psychiatry training.

Improving patient access, and making us more effecient is the best way to keep the primary arguments of psychologists and even NPs from giving misguided ammunition to politicians. Ultimately, these pesky scope of practice expansions will be held at bay and maintain patient safety.

 

[Daniel Carlat]

This was brought to Carlat's attention in the forum, and he said he is very aware of how psychiatry differs in scenarios other than the outpatient, yet he was still of the same opinion.

The only type of scenario I can think of that fits Carlat's mentioning is an outpatient setting where one only sees patients with disorders that require much more psychosocial intervention than pharmacologic, do not have complicating medical problems, only require low dosages of medications, and none of the psychotropics given out are mood stabilizers, antipsychotics, or B-blockers. Even then, a medical issue can come up from time to time. That certainly is only a small part of the spectrum of our field.

While the research is sparse, all surveys of psychiatric practice that I am aware of have consistently shown that outpatient psychiatrists almost never do physical exams, while inpatient psychiatrists often do. In addition, psych residents do physical exams much more frequently than psychiatrists who have finished their residencies. You can read some of this evidence here and here.

It may seem that I am demeaning the role of medicine in psychiatry but truly in this case you are shooting the messenger. If we really feel we need 4 years of medical school to be psychiatrists, we had better start proving it by doing the things that other doctors do.

 

[nancysinatra]

While the research is sparse, all surveys of psychiatric practice that I am aware of have consistently shown that outpatient psychiatrists almost never do physical exams, while inpatient psychiatrists often do. In addition, psych residents do physical exams much more frequently than psychiatrists who have finished their residencies. You can read some of this evidence here and here.

It may seem that I am demeaning the role of medicine in psychiatry but truly in this case you are shooting the messenger. If we really feel we need 4 years of medical school to be psychiatrists, we had better start proving it by doing the things that other doctors do.

Thank you for your response, Dr. Carlat. With all due respect, I was under the impression you felt that medicine wasn't needed for the treatment of psychiatric illness, not that it simply wasn't being used.

I can't disagree that it sometimes isn't used. I know attendings in my own program who appear to have "lost" their medicine. These attendings are the ones who ask interns which antihypertensives to give. This is a well known hazard of the profession, which happens to some people. However this does not excuse its happening to all people, and I do not think that means that patients are in any less need of good, well rounded medical care. If anything leaders in psychiatry should be advocating for the thing you mentioned above--doing what doctors "do"--i.e. providing care to patients.

Perhaps an example of where general medical knowledge is essential in psychiatry would be eating disorders. I'm just an intern, and I realize my knowledge is less than yours, but I would be interested in how you would assess and treat a bulimic or anorexic patient without having attended medical school. As you know, these patients may have cardiac, GI, and electrolyte abnormalities (among other things) that if not recognized can be fatal. How could an outpatient Dr. of Mental Health assess and recognize those abnormalities? They are frequently missed by PCPs and pediatricians. If you have a moment, I would be really interested in a specific discussion of this matter, since you are advocating for removing this component of our training, and yet these patients still need care and still frequently go unrecognized and die from their disease.

Just to cite some examples, you can't always just tell a patient to increase calories right away--there are concerns like refeeding syndrome, which requires you follow certain electrolytes. People can die from this. You have to know when to admit a patient (both to psych and to medicine), and god forbid, when to require (against a patient's wishes) an NG tube. Psychiatry is not always just prescribing meds and sitting in a chair doing therapy.

Also, Dr. Carlat, I don't feel you have answered most of the questions brought up earlier in this forum. For example, radiologists and pathologists don't do physical exams either, and neither do many other specialists (or else they do extremely truncated physical exams. Good grief most attendings who supervise residents don't even do physical exams!) You could call our mental status exam a physical exam similar to the exam done by some sub-specialists.

 

[Daniel Carlat]

Perhaps an example of where general medical knowledge is essential in psychiatry would be eating disorders. I'm just an intern, and I realize my knowledge is less than yours, but I would be interested in how you would assess and treat a bulimic or anorexic patient without having attended medical school. As you know, these patients may have cardiac, GI, and electrolyte abnormalities (among other things) that if not recognized can be fatal. How could an outpatient Dr. of Mental Health assess and recognize those abnormalities? They are frequently missed by PCPs and pediatricians. If you have a moment, I would be really interested in a specific discussion of this matter, since you are advocating for removing this component of our training, and yet these patients still need care and still frequently go unrecognized and die from their disease.

Nancysinatra--I have never advocated to remove medicine from our training. Here are my positions, just to be clear.

1. I think psychiatrists are over-trained in medicine, and that we can profitably pare down the amount of medicine in our training to those aspects that are most relevant to psychiatry. And here, no less a champion of the value of medicine in psychiatry as Ron Pies has agreed: "I believe that there could be a concomitant reduction in the total length of medical school training, as my colleague, Dan Carlat, has proposed on his own blog site." Here Dr. Pies was proposing a reform in psychiatric training that would trade some unnecessary medical school training for addtional training in the humanities during residency. (You can find this in one of his responses to comments on this article.) My proposal would mirror the experimental Doctor Of Mental Health degree that existed for several years as a combined UCSF/Berkeley program in the 1970s. This was a 5 year program, in which students attended two years of truncated medical school followed by three years of psychiatric residency. The specifics of such a program would be critical, and would need to provide enough medical training to recognize the presence of medical problems in patients and to understand how to triage patients to the right specialist for appropriate medical treatent. At the same time, this training would incorporate the reality that psychiatrists do not themselves conduct the workup and treatment of non-psychiatric illness.

2. My second proposal is that we can create a training program for psychologists that will adequately prepare them for limited prescribing privileges, and that this is a quick fix to a current shortage of psychiatrists that is expected to worsen over the near term future. This is necessary for the public health while psychiatry goes through the process advocated by Dr. Pies of "getting its own house in order."

 

[Daniel Carlat]

Also, Dr. Carlat, I don't feel you have answered most of the questions brought up earlier in this forum. For example, radiologists and pathologists don't do physical exams either, and neither do many other specialists (or else they do extremely truncated physical exams. Good grief most attendings who supervise residents don't even do physical exams!) You could call our mental status exam a physical exam similar to the exam done by some sub-specialists.

I agree that medicine is a diverse field and that, by definition, specialists within the field focus on different professional jurisdictions. Radiologists don't do physical exams or prescribe drugs for the most part; however, everything they do is based on understanding the pathophysiology of medical diseases. This is also true of pathologists.

Psychiatry is different in that our core task involves psychological investigation and understanding the behavioral phenomenology which we then match to a list of epidemiologically validated disease entities. Yes, we certainly need to understand some medicine for ruling out medical illness and for managing psychopharmacologic treatment, but on a day to day basis we require far less medical knowledge than any other specialists.

 

[Daniel Carlat]

I can't disagree that it sometimes isn't used. I know attendings in my own program who appear to have "lost" their medicine. These attendings are the ones who ask interns which antihypertensives to give. This is a well known hazard of the profession, which happens to some people. However this does not excuse its happening to all people, and I do not think that means that patients are in any less need of good, well rounded medical care. If anything leaders in psychiatry should be advocating for the thing you mentioned above--doing what doctors "do"--i.e. providing care to patients.

I have no arguments with this. The question is where psychiatry is heading at this moment in history. This listserv is populated mainly by residents and interns. Fresh out of medical school, you are still adept at medical diagnosis and treatment and you are eager not to lose these skills. But unless psychiatry changes itself radically as a profession, you will inevitably lose these skills by attrition once you leave the medical centers and go into outpatient practice.

If psychiatry wants to make itself a truly medical profession, it will have to make massive changes in its professional guidelines, training, and culture. It will have to do something to encourage office based psychiatrists to be, truly, primary care doctors, and do physical exams on all patients, basic medical workups and basic medical treatment. The problem is that we already have such a profession: family practitioners. It will be very hard to produce psychiatrists who have the knowledge and skills to be primary care doctors as well as the necessary understanding of the intricacies of psychopharm as well as the skills in empirically validated psychotherapies . I would anticipate several more years of training required to produce such specialists.

Maybe that is precisely where psychiatry is headed.

 

[whopper]

It may seem that I am demeaning the role of medicine in psychiatry but truly in this case you are shooting the messenger.

Thanks for your response and clarification.

I do, however, still think the article in Psychology Today was misleading. It was written in a style that seemed to apply to all psychiatry. Laymen and non-medically trained psychologists could read that article and get a very different impression than the posts you put up here, and Psychology Today is a mainstream publication available in several outlets geared towards the laymen.

There are scenarios where I can see outpatients not needing medical intensive services, but there are still many that do. E.g. antipsychotic use by ADA and APA recommended guidelines require some medical oversight. Antipsychotics have uses in augmentation of of the treatment of depression and OCD. From my own outpatient experience, over half of my patients are on antipsychotics. Am I an antipsychotic pusher? I don't think so. Several psychotic and manic people get better to the point where they don't need to be in inpatient anymore.

If we really feel we need 4 years of medical school to be psychiatrists, we had better start proving it by doing the things that other doctors do.

In my inpatient setting, I actually often do. On the order of about once to every 2 months, I've been involved in situations where the consultant, IMHO, blew off the patient, and my medical skills were required to intervene. E.g. a patient who was pregnant that the Ob-gyn doctor wrote was not pregnant (I had to order serial B-hcg tests to confirm because we did not have an ultrasound in the psychiatric hospital), a patient with NPH labelled psychotic from the medical hospital, correctly diagnosing a patient with neurosarcoidosis as the cause of his violent outbursts who had been diagnosed as psychotic for years.

At least on the order of weekly, even in my outpatient work, I get a patient with medical problems where reading the documentation such as CT scans, labs, PCP reports, does affect my decision on their treatment. My medical training was needed to read and understand their surgery report.

I'd say that in about 50% of my outpatient cases, my medical skills do come into play. E.g. a patient with an anxiety disorder that is treatment resistant and the patient has hypertension. I call up the PCP and ask if his BP med could be switched to a beta-blocker. I am vigilant over all my diabetic patients' metabolic status, and seemingly even more so than their PCP by my patients' accounts. Most of my psychotic patients have several medical-related issues and do not have a PCP. I have to often times explain to them the nature of their medical problems and why they need a PCP, and then show them the results of their metabolic testing, the risks they have of a heart attack or stroke, etc.

All in all, it comes down to at least a few times a week, if not daily, where my medical skills are needed.

 

[Sneezing]

I agree that medicine is a diverse field and that, by definition, specialists within the field focus on different professional jurisdictions. Radiologists don't do physical exams or prescribe drugs for the most part; however, everything they do is based on understanding the pathophysiology of medical diseases. This is also true of pathologists.

Psychiatry is different in that our core task involves psychological investigation and understanding the behavioral phenomenology which we then match to a list of epidemiologically validated disease entities. Yes, we certainly need to understand some medicine for ruling out medical illness and for managing psychopharmacologic treatment, but on a day to day basis we require far less medical knowledge than any other specialists.

This just sings of ignorance. Psychiatry doesn't focus on the understanding of pathophysiology of medical diseases? Every day I get pimped on this stuff. Radiologists in private practice let their understanding of disease slip to patheticness, too. They stop offering up differentials on their reports and eventually every report says "verify clinically" and "suggest further imaging with MRI/US/CT" They are often times worthless. Surgical specialists most often don't care what they have to say, but only want them there for legal risk distribution.

Psychiatry is the practice of medicine. Physicals exams are not the defining hallmark of a physician. How many physical exams do ID docs do? A picture of an open wound is all they really need. Same thing for derm, that's why they also have telederm practices. We are physicians and we are psychiatrists.

Medical school is necessary. Patients are seldom without other somatic complaints. We know how to effeciently tease those out. Why? Because we have already seen hundreds to dozens of others with legitimate complaints. Psychiatry doesn't happen in a vaccum even in an outpatient setting.

Your issue is that some outpatient psychiatrists got lazy. To try and sell out the entire profession and patients based on one practice venue is ludacris. The law of unintended consequences would be tremendous.

It is far better to be overtrained for your job then undertrained.

You also forget about collegial respect. There is something to be said for having the same training as all our other bretheren. If some fantismal new degree is created that you advocate for, you will have torpedoed the respect of other physicians. Do you really think physicians would respect the professional opinion of some new mental health degree? I have had other physicians tell me to my face when I mentioned that I was going into psych, that our specialty isn't real and mental illness is a joke. And if this midlevel (that's what it would ultimately be) made suggestions for further traditional workups or even physical exam comments, they would be laughed at. These are the undercurrent issues that few would openly admit to.

 

[OldPsychDoc]

...Your issue is that some outpatient psychiatrists got lazy. To try and sell out the entire profession and patients based on one practice venue is ludacris. The law of unintended consequences would be tremendous.
....

Sneezing--I think this statement borders on hysteria. For all of its strengths and weakness, psychologist prescribing is NOT "selling out the profession", any more than CRNAs "sold out" anesthesia, or NPs and PAs have "sold out" primary care. Try to tone down the "all or nothing" thinking.

 

[Sneezing]

I call it passion. I'll try to be more selective with my word choices. It is hard though, considering some of the things I have seen/experienced.

Have you looked into the anesthesiology forums much? I could rant on this topic, too. Although, it would not be appropriate for the topic at hand.

 

[whopper]

Sneezing, while I disagree with Dr. Carlat, you got to pay some respect. The man has done a lot to advance our field and offer fresh discussion on topics that needed to be discussed for several years.

Your issue is that some outpatient psychiatrists got lazy. To try and sell out the entire profession and patients based on one practice venue is ludacris. The law of unintended consequences would be tremendous.

In (pseudo) defense of Sneezing, I've seen several outpatient psychiatrists go "lazy." In a setting such as outpatient, where medical skills are not needed as much, I have seen several psychiatrists lose their medical skills. In fact I've even seen it with inpatient doctors. I've often ranted about the psychiatrists that ordered frivolous consults for a patient with a BP of 138/45 and called it hypertension.

That, if anything, actually bolsters the argument that we psychiatrists keep up with our medical skills.

 

[Anasazi23]

Maybe psychiatrists that have private practices that require the presence of a Queen Anne chair don't have much use for their medical training, but come work a shift in my ED or consult to one of the 12 subspecialty ICUs my team covers and we'll see how much of your general medical knowledge and physical exam skills your patients can afford for you to lose.

QFT (Quoted for Truth)

 

[Sneezing]

you got to pay some respect

I respect patients first and foremost.
I respect the long rich history of physicians second.
I respect the field of psychiatry thirdly.
These things are all encompassed in the oath.

Dr. Carlat's newsletter is an excellent source of medical knowledge and highly regarded. I hope I may have as an esteemed of a career some day with such a wide sweeping impact. There is no debate in this point.

Arethra Franklin sings it best.

 

[OldPsychDoc]

I call it passion. I'll try to be more selective with my word choices. It is hard though, considering some of the things I have seen/experienced.

Have you looked into the anesthesiology forums much? I could rant on this topic, too. Although, it would not be appropriate for the topic at hand.

I like passion. If I didn't have passion I wouldn't get out of bed in the morning to see my patients...

But I wouldn't judge the MDA/CRNA issue, nor the role of DNPs, nor the roles of NPs and CNSs by the statements made on internet forums...even relatively sophisticated ones like SDN. I'd rather go by what I see everytime the MDAs and CRNAs chat cordially as they set up my ECT patients, or my discussions about my patients' medical issues with the DNP on our floor, or the passion for her patients that "my" CNS displays in our supervision sessions. Real life, working things out in the Real World. That's what matters. And I've noticed that in Real World interdisciplinary relationships, Karma (collegiality) tends to win out over Dogma (politics).

 

[notdeadyet]

Your karma ran over their dogma?

 

[nancysinatra]

I have no arguments with this. The question is where psychiatry is heading at this moment in history. This listserv is populated mainly by residents and interns. Fresh out of medical school, you are still adept at medical diagnosis and treatment and you are eager not to lose these skills. But unless psychiatry changes itself radically as a profession, you will inevitably lose these skills by attrition once you leave the medical centers and go into outpatient practice.

If psychiatry wants to make itself a truly medical profession, it will have to make massive changes in its professional guidelines, training, and culture. It will have to do something to encourage office based psychiatrists to be, truly, primary care doctors, and do physical exams on all patients, basic medical workups and basic medical treatment. The problem is that we already have such a profession: family practitioners. It will be very hard to produce psychiatrists who have the knowledge and skills to be primary care doctors as well as the necessary understanding of the intricacies of psychopharm as well as the skills in empirically validated psychotherapies . I would anticipate several more years of training required to produce such specialists.

Maybe that is precisely where psychiatry is headed.

Thank you Dr. Carlat for responding and answering several questions. You've given a much clearer picture of what you mean with your proposals. I still don't feel like I would want to pursue the alternative type of training you are proposing--and one especially huge reason is that many people like myself went to medical school not sure what specialty we'd eventially choose. Prior to medical school I would not have gone down the road you're suggesting. I think the main people who would are the same people who currently choose to become clinical psychologists, but perhaps want a "little more" medical-type training.

Anyway I would be thrilled if psychiatry would become MORE focused on medicine--both basic and acute. And while I understand what you're saying about the perspective that trainees have, not all of us PLAN to become outpatient practioners treating primarily depression and anxiety (which I'm assuming is the type of outpatient practice you're describing). Remember psychiatry includes sleep d/o, pain medicine, C/L, geriatrics, addiction, neuropsych, C&A, and other subspecialties. I don't really feel you are doing full justice to the whole range of things psychiatrists currently do.

One thing I don't understand is the dichotomy in psychiatry between inpatient and outpatient. Why do psychiatry attendings not have to cover the inpatient unit for some number of weeks per year, like medicine and peds attendings do (at least at hospitals I've seen?) My understanding is that medicine/peds resorts to hospitalists only when they feel they can do nothing else. But in psych you'll sometimes see these dinosaur inpatient attendings whose entire career is only inpatient. Meanwhile other people ONLY do outpatient. Sure there are IM doctors who just do ambulatory, but to be academic and admit patients to hospitals, don't they have to put in some number of weeks covering the wards?

Then on the inpatient psych unit, it's usually residents who do any medical work. (Ugh, ask a psych attending to do a neuro exam, and see what happens!) And look at what kinds of patients we reject from the psych floor. We reject any patient that is even slightly medically sick. By contrast surgery doesn't reject any patient from their floor just because they aren't "a perfect candidate for surgery" or whatever. They handle all sorts of medical stuff and only really call medicine if it's getting to the point that they NEED to. I personally wonder if this is really necessary on our part (especially since the rejection threshold varies from psych ward to psych ward), and think it has more to do with nursing than anything else (yes it is explained as "they can't have IVs on the psych floor" but I don't believe that's the real reason--those patients still get the IVs, they just get them on the medicine floor). I think that's where psychiatrists start to lose their medicine. The exodus to outpatient practices consisting solely of depression/anxiety patients must be where it continues.

And why do we break our training up into separate years of inpatient and outpatient? If anything psychotherapy needs to be done and learned long term. Of all the services, WE should be having continuity clinics. Instead we have a dichotomous situation which only contributes to psychiatrists forgetting their medical knowledge.

And what about whenever the pathophysiology of a disease GETS understood--we hand it off to another specialty? Take Huntingtons. That used to be cared for by psych, didn't it? Well then we found out it was genetic, so off it went to neuro. Back in the day, didn't neurosyphillis patients used to go to psych hospitals? The minute antibiotics came around, or LPs started to be required--off it went to medicine I guess!

The minute something physical can be done for a disease, psych washes its hands of that disease. I really disagree with this--I think we should take pride in treating all the illnesses in our realm, but that's just me. By contrast, look at neurology. Neurology used to be known as a field that could not "treat" any of its illnesses. Neuro attendings used to sit around and talk about localizing lesions all day long. Then TPA came along and now they have to act fast. You might think neuro would have handed strokes over to medicine because they just weren't suited to act quickly like that, but instead, they adapted. And as neuroimaging got better, neurologists learned to read it too.

So why can't psychiatrists learn to incorporate new skills into our repertoire? AIDs dementia could be in our area, but then AIDS patients would have to come to our floor--and--gasp!--they have fevers! We might have to talk directly to ID! Our nurses would be calling every single minute yelling to transfer the patient away. Our attendings would be scared witless.

That's how it goes. Yes I think it's terrible and I'm not sure how I feel about this field now that I've seen it from the inside. But I would never advocate for less medicine--only for more. I would prefer to learn to treat these patients myself (competently and well--I'm not asking to do things without training)--then just go off to some office with a leather chair and do nothing but talk all day.

Thanks again, Dr. Carlat--I can't respond to all your points but I appreciate your answering questions.

 

[AleksPsych]

And what about whenever the pathophysiology of a disease GETS understood--we hand it off to another specialty? Take Huntingtons. That used to be cared for by psych, didn't it? Well then we found out it was genetic, so off it went to neuro. Back in the day, didn't neurosyphillis patients used to go to psych hospitals? The minute antibiotics came around, or LPs started to be required--off it went to medicine I guess!

The minute something physical can be done for a disease, psych washes its hands of that disease. I really disagree with this--I think we should take pride in treating all the illnesses in our realm, but that's just me.

nancysinatra: I think you make a great point. Here is my two cents...

The current list of psychiatric disorders is an amalgam of conditions that are brain diseases best understood at the level of the brain (e.g., schizophrenia, bipolar), and disorders that involve the brain but are best understood at a psychological level of analysis (e.g., personality disorders, anxiety disorders). The former disorders are best understood and managed from the medical perspective, while the latter are most appropriately handled from a psychological perspective (i.e., managing behaviours, exploring life histories, meanings, and processing emotions).

What does not make sense to me is this... Psychiatry is a medical specialty organized around diagnosing and treating symptoms, i.e., cognitive, emotional, and behavioural symptoms. Other medical specialities (generally speaking) are organized around the bodily organ they treat. For example, neurology diagnoses and treat diseases of the brain and nervous system. But, does psychiatry diagnose and treat diseases of the brain? Some psychiatric conditions are brain diseases, and some are not (despite obviously involving the brain). It is true that these disorders involve cognitive, emotional, and behavioural symptoms, but they are not brain diseases per se, i.e., they are a combination of personality dispositions and life experiences and not the result of "broken" brains. (I'm oversimplifying here obviously).

I think the proposal of combining neurology and the medical diseases of psychiatry, into one specialty that treats brain diseases, makes the most logical sense to me. This speciality would deal with every single disease of the brain (e.g., Parkinson's, Huntington's, schizophrenia, bipolar disorder, all dementias), and these physicians would be the only "brain doctors." The patients who are currently psychiatric whose disorders are best understand from a psychological level of analysis would be pushed over to clinical psychology and social work. Yes, these patients will have medical disorders, but these conditions can be handled by PCPs and internists (the same as diabetes is handled by endocrinologist, even if a neurologist is treating the Parkinson's disease). A point I should make is this is not splitting patients based on brain versus mind. Obviously, all "psychological" disorders involve the brain to some degree, but this does not make them brain diseases anymore than low intelligence (which is partially genetic and involves neurological functioning and can impair a person's functioning) is a brain disease. The point I'm making is the level of analysis that most fits these patients is the psychological level. For example, borderline patients most seem to benefit from learning skills to tolerate distress and control impulses (i.e., the behavioral level of analysis is most fitting here, even though the brain is involved in affect and impulse dysregulation). These types of patients might first be seen by the "brain doctors" to rule out medical causes of their symptoms (e.g., brain tumors, infections), and then sent to psychological therapists when they have been medically cleared. I believe this represents the best in patient care.

 

[snarfer]

nancysinatra: I think you make a great point. Here is my two cents...

What does not make sense to me is this... Psychiatry is a medical specialty organized around diagnosing and treating symptoms, i.e., cognitive, emotional, and behavioural symptoms. Other medical specialities (generally speaking) are organized around the bodily organ they treat. For example, neurology diagnoses and treat diseases of the brain and nervous system. .

Alekspsych-there are cyts in the liver/kidneys/uterine clinicians don't treat. Structural heart defects, MSK damages, white matter changes in the brain, etc. that clincians do not treat. Patient with asymptomatic poor glucose control, palmar fibromatosis, elevated BP go for years without treatment. Patients often do not require treatment if they are asymtomatic or not fucntionally impaired. The definition of medical diseases is that symptoms must exist without or with structural or objective physical findings. This is how physicians used to practice medicine prior to imagings, labs, etc....

Regarding psychiatrists forgetting general medical knowledge. This is fairly common in the other medical specialties too. Not that this makes it right but pediatricians forget adult medicine, surg forgets how to manage diabetes, cholesterol, psychiatry. OB/GYN forget how to treat half of the world's population. Point is, this happens alot in the other fields.

It has been 20 years since we made any progress treating depression (ssri) and 50 years with schizophrenia. If psychiatrists are not doing focused physical exams, ie. AIMS or using their medical skills per the two UK studies-seems like what we need is more medical training for psychiatrists instead of less.

 

[kugel]

Which means that that psychiatrists do what, exactly?

That's right:

http://ecx.images-amazon.com/images/I/31E686YHDKL._SL500_AA300_.jpg

Upholstery?

 

[AleksPsych]

Alekspsych-there are cyts in the liver/kidneys/uterine clinicians don't treat. Structural heart defects, MSK damages, white matter changes in the brain, etc. that clincians do not treat. Patient with asymptomatic poor glucose control, palmar fibromatosis, elevated BP go for years without treatment. Patients often do not require treatment if they are asymtomatic or not fucntionally impaired. The definition of medical diseases is that symptoms must exist without or with structural or objective physical findings. This is how physicians used to practice medicine prior to imagings, labs, etc....

I'm not sure how this relates to my point of psychiatry being a speciality organized around symptoms, and not a bodily system/organ. Can you clarify?

I disagree with you on the definition of disease. Dis-ease in the most general sense refers simply to "suffering." In the medical sense most definitions of disease would say a disease is an abnormal condition within the organism that impair bodily functions, associated with specific symptoms and signs. There are always going to be one or two or three specific cases where this does not apply, but generally speaking this is the definition. Diseases existed before imaging, labs, etc existed, and they were understoo based mostly on their symptoms. The reason the DSM-IV included the word "disorder" and not disease is because these entities are not really understood in a such a manner that allows us to classify them as diseases (i.e., underlying pathophysiology is not well understood). Rather, they are syndromes that impair people's lives.

 

[mishavrach]

Nancysinatra--I have never advocated to remove medicine from our training. Here are my positions, just to be clear.

1. I think psychiatrists are over-trained in medicine, and that we can profitably pare down the amount of medicine in our training to those aspects that are most relevant to psychiatry. And here, no less a champion of the value of medicine in psychiatry as Ron Pies has agreed: "I believe that there could be a concomitant reduction in the total length of medical school training, as my colleague, Dan Carlat, has proposed on his own blog site." Here Dr. Pies was proposing a reform in psychiatric training that would trade some unnecessary medical school training for addtional training in the humanities during residency. (You can find this in one of his responses to comments on this article.) My proposal would mirror the experimental Doctor Of Mental Health degree that existed for several years as a combined UCSF/Berkeley program in the 1970s. This was a 5 year program, in which students attended two years of truncated medical school followed by three years of psychiatric residency. The specifics of such a program would be critical, and would need to provide enough medical training to recognize the presence of medical problems in patients and to understand how to triage patients to the right specialist for appropriate medical treatent. At the same time, this training would incorporate the reality that psychiatrists do not themselves conduct the workup and treatment of non-psychiatric illness.

2. My second proposal is that we can create a training program for psychologists that will adequately prepare them for limited prescribing privileges, and that this is a quick fix to a current shortage of psychiatrists that is expected to worsen over the near term future. This is necessary for the public health while psychiatry goes through the process advocated by Dr. Pies of "getting its own house in order."

Dr. Carlat,
It appears to me that you are wrong on both accounts.

1. Psychiatrists are under-trained in medicine. While the effort is to finally, after almost a century of wondering, bring psychiatry in the realm of medicine, you are advocating turning psychiatrists into doctors by name only with limited understanding of modern medicine. Psychiatry is in realm of medicine (evolutionary, neurobiological bases for psychopathology; use of medical tools for research, and soon diagnosis, and medical methods for treatment - medication, TcMS, ECT, VNS, etc.) and should be treated as any medical sub-specialty - internship, primary care residency, board eligibility and specialty training. One thing missing in psychiatry is classification based on neurobiology - just a matter of time.

2. You are suggesting limited prescribing privileges for psychologists. Limited in what, may I ask?
Type of patients they treat? - without medical training the psychologists won't be able to tell whom not to treat.
Limited in choice of medications (which one?) or the dose? How is that possible?
Once, the license is issued, you can't control (micromanage) individual practices.

Here are my proposals for psychiatrists' shortage: train other docs (peds, FP, internists, OBGYN's) in limited evaluation and treatment of psychiatric disorders - at least they already know how to prescribe and when to refer. Reduce psychotherapy training for psychiatric residents to CBT, mindfulness, ACT, etc and get rid of psychoanalytic/psychodynamic Tx (that alone will reduce time and confusion). Those who want to learn more will do it after the residency.
Train more PNP and PA's in psychiatric sub-specialty to work with psychiatrists
Increase admission to med schools and have more schools. Someone jokingly suggested converting law schools into medical and kill two birds.

"getting its own house in order" requires a separate forum, not just the thread.

FWIW

 

[Ronpies]

from Ron Pies MD [with apologies for the bad formatting]

Since my friend and Tufts colleague, Danny Carlat, has seen fit to
quote me (#172), I thought I should take the opportunity to clarify my own views on medical training for psychiatrists; as well as say a few words
on how this applies to psychologists seeking so-called "prescribing
privileges" (read: "the wish to practice internal medicine").

First, as Dr. Carlat indicated, I did say that a re-examination
of the medical school curriculum is worthwhile, and that some
condensation in the area of the basic sciences may indeed be
feasible. Ironically, I still remember all the steps in the TCA
(Krebs) Cycle, using the same mnemonic I created when I was a
medical student! But does the Krebs Cycle really enter into my
everyday medical skills and practice? Not so much. Was it wasted
time? No--it helped me learn a kind of mental discipline that I value
to this day. But I would probably favor a condensation of the basic
science curriculum in medical school, such that at least 6 months
could be eliminated. I may be wrong about the wisdom of that. I
would need to see a "Flexner-type" commission review that issue in
detail. But in any case, this is a totally separate issue from either
(1) the need to understand internal medicine, neurology, pathophysiology,
etc. as a psychiatrist; and (2) granting "prescribing privileges" to
those who lack substantial medical training.

With respect to the first issue: one of my mentors during residency
used to say, only half-facetiously, "In psychiatry, you can do biology
in the morning and theology in the afternoon!" I think that's true--but
you better hang on to your knowledge of biology! Unless you plan to do
nothing but existential psychotherapy or psychoanalysis--and never prescribe medication--you had better know a lot about internal medicine, neurology, neuroendocrine systems, pharmacodynamics, pharmacokinetics, etc. And no--it's not enough to send your patient
for "medical clearance" by the PCP. Patients are not "set and forget"
automatons: their medical issues and problems develop and evolve over time, and this requires constant vigilance on the part of the psychiatrist.

And even if you are in the "psychotherapy only" group, you had better
know enough to know when your patient's "depression" is really due to
an early pancreatic cancer, a paraneoplastic syndrome, B12 deficiency,
etc. Otherwise, you will wind up with patients like composer George
Gershwin, who underwent years of psychoanalysis for his "depression",
while suffering all the time from an undiagnosed brain tumor. (Then there
was Jack Benny, whose pancreatic cancer presented as depression...)

In the best of all possible worlds, I would like to see medical school
condensed to 3 years, with greater emphasis on clinical skills; and
psychiatric residency expanded to 5 years, with greater emphasis on
both medical/neurological science and psychotherapy training--plus
exposure to the "humanities" (philosophy, literature, etc.). I have also
suggested that a combined neurology-psychiatry residency may be
worth exploring, though this would have to be done very carefully, so
that neither field was simply "reduced" to the other.

But before granting "prescribing privileges" to those without substantial
medical training, we would need to determine if a condensed medical school curriculum is safe and effective for physicians. If carefully controlled
studies show that it is, then anybody (a psychologist, a social worker,
a historian) would be free to enroll in this new, streamlined curriculum.
Absent such a scenario, the next-best approach (much inferior, in my view) would be a very careful longitudinal study of graduates of the type of
program envisioned (but never enacted in any state!) by the American
Psychological Association, in their very comprehensive model curriculum
for "prescriptive authority." In many respects, this proposed curriculum
resembles elements of medical school and medical internship, though it is
arguably no substitute for either. See: http://www.apa.org/about/
governance/council/policy/rxp-model-curriculum.pdf. Perhaps in some respects, Dr. Carlat has a program like this in mind. In any event, the present training programs for "prescribing psychologists" are nowhere near this level of clinical rigor. (Nor, by the way, do present psychology "prescribing" curricula remotely approach the level of clinical rigor present in Psychiatric Nurse Practitioner programs).

I have more detailed comments on the Psychiatric Times website for those who want their eyes to glaze over! ( see: http://www.psychiatrictimes.com/display/article/10168).

The bottom line for those just entering psychiatry: first and foremost, you must be good physicians. For those now in their early psychiatric careers, don't lose those medical skills; keep up with neurology and internal medicine; check your patients' blood pressure and pulse; order those lab tests; do circumscribed neurological exams--and read the best poetry, philosophy and literature you can get your hands on! Or, as the Russian writer Isaac Babel put it, in a short story, "You must know everything!"

Best regards,
Ron Pies MD

 

[snarfer]

I'm not sure how this relates to my point of psychiatry being a speciality organized around symptoms, and not a bodily system/organ. Can you clarify?

I disagree with you on the definition of disease. Dis-ease in the most general sense refers simply to "suffering." In the medical sense most definitions of disease would say a disease is an abnormal condition within the organism that impair bodily functions, associated with specific symptoms and signs. There are always going to be one or two or three specific cases where this does not apply, but generally speaking this is the definition. Diseases existed before imaging, labs, etc existed, and they were understoo based mostly on their symptoms. The reason the DSM-IV included the word "disorder" and not disease is because these entities are not really understood in a such a manner that allows us to classify them as diseases (i.e., underlying pathophysiology is not well understood). Rather, they are syndromes that impair people's lives.

Disclosure- I like and respect psychologists! Two of my siblings are clinical psychologists.

Disease as defined in Dorland's med dictionary-any deviation from or interruption of the normal structure of function of any part, organ, or system (or combination of) of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.

My point is that psychiatry disorders or diseases are essentially brain disorders which manifest behaviorally. Thereby our work is similar to the other specialties. This has been discussed in prior posts but the pathophysiology of many 'medical' disorders are not that well known.

I can't comment why the DSM use the term disorders vs. diseases. In medicine, you can use both terms interchangeably. We also use words like issues, illness for practically all symptoms relating to any organs.

There are lots of cross specialties treatment. Many dementia patients end up being treated by psychiatrists. Kids with Retts, Autism, seizure d/o, chromosomal abnormalities invariably end up at child psychiatrists for treatment. It's great that the geneticists, dev. medicine, child/adult neuro
diagnose these patients but they usually end up with us for treatment.

We are at the cross road in psychiatry right now. We have mental health parity laws. President Obama had increased research funding for mental health. Awareness and acceptance are getting better. Numerous projects are just under way (it's Sat night and i'm working on a new grant). And we're making progress understanding disturbances at the neural circuitry level relating to genome, the environment. And not only in SZ and bipolar but also in anxiety, depression, ADHD, eating disorders, autism, OCD, PTSD,etc.

We cannot retreat from the medical aspect of mental health by becoming more subspecialize or combining with neuro. To do so would be akin to abandoning those we serve. I agree with Misachvech and others. We need to get primary care doctors, NPs/PAs, and other specialties involved. We need to collaborate with our colleagues in psychology further. I recommend any psychologists who seek to gain medical knowledge in mental health to do so by getting NP or PA degrees instead of wasting time and financial resources with lobbying efforts.

 

[snarfer]

In the best of all possible worlds, I would like to see medical school
condensed to 3 years, with greater emphasis on clinical skills; and
psychiatric residency expanded to 5 years, with greater emphasis on
both medical/neurological science and psychotherapy training--plus
exposure to the "humanities" (philosophy, literature, etc.). I have also
suggested that a combined neurology-psychiatry residency may be
worth exploring, though this would have to be done very carefully, so
that neither field was simply "reduced" to the other.

Best regards,
Ron Pies MD

Dr. Pies-bravo. I think many medical students and residents would rejoice at the idea of compressing medical school to 3 years.


Regarding the idea of a combined neuro-psychiatry residency. It should not be difficult to get some data as there are several combined programs already in existence in the US. They are not particularly popular, however, with medical students for various reasons.

 

[AleksPsych]

Disclosure- I like and respect psychologists! Two of my siblings are clinical psychologists.

Disease as defined in Dorland's med dictionary-any deviation from or interruption of the normal structure of function of any part, organ, or system (or combination of) of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.

My point is that psychiatry disorders or diseases are essentially brain disorders which manifest behaviorally. Thereby our work is similar to the other specialties. This has been discussed in prior posts but the pathophysiology of many 'medical' disorders are not that well known.

I can't comment why the DSM use the term disorders vs. diseases. In medicine, you can use both terms interchangeably. We also use words like issues, illness for practically all symptoms relating to any organs.

There are lots of cross specialties treatment. Many dementia patients end up being treated by psychiatrists. Kids with Retts, Autism, seizure d/o, chromosomal abnormalities invariably end up at child psychiatrists for treatment. It's great that the geneticists, dev. medicine, child/adult neuro
diagnose these patients but they usually end up with us for treatment.

We are at the cross road in psychiatry right now. We have mental health parity laws. President Obama had increased research funding for mental health. Awareness and acceptance are getting better. Numerous projects are just under way (it's Sat night and i'm working on a new grant). And we're making progress understanding disturbances at the neural circuitry level relating to genome, the environment. And not only in SZ and bipolar but also in anxiety, depression, ADHD, eating disorders, autism, OCD, PTSD,etc.

We cannot retreat from the medical aspect of mental health by becoming more subspecialize or combining with neuro. To do so would be akin to abandoning those we serve. I agree with Misachvech and others. We need to get primary care doctors, NPs/PAs, and other specialties involved. We need to collaborate with our colleagues in psychology further. I recommend any psychologists who seek to gain medical knowledge in mental health to do so by getting NP or PA degrees instead of wasting time and financial resources with lobbying efforts.

The definition of disease that you give in this post is the exact same definition I gave in the post you referenced. However, the definition you gave in an earlier post was not the same.

All psychiatric disorders are not brain diseases. While it is true that the pathophysiology of many medical disorders is unknown (btw, this is a typical argument that psychiatrists make to validate the medicalization of all the conditions they treat), no other speciality consists of as many disorders of unknown pathophysiology as psychiatry does. I don't disagree that all psychiatric conditions involve the brain to some degree, I just deny that they are diseases in the same sense as Huntington's disease, AZ disease, etc. For example, changing parenting styles doesn't treat seizure disorders in children but it does treat conduct disorder. Alzheimer's disease patients cannot be bribed into stopping their memory impairment, but substance use disorder patients stop using drugs with bribes (it's just called contingency management and it has loads of scientific research to promote it's use).

The fact that some psychiatrists treat dementia, autism, and seizure disorders means some of the conditions they treat are brain diseases. Yes, the pathophysiology of autism is not completely known but the likelihood that it is not a brain disease in the true sense of the word disease is slim to none. My point is these conditions should be treated by brain disease physicians, whatever you want to call them (neurologists or neuropsychiatrists). I'm not suggesting the removal of medicine from psychiatry, I'm suggesting the true diseases psychiatry treats become a part of a brain disease speciality. For the record, I do not think general clinical psychologists should prescribe medications.

If I can be a psychologist for one second... I'm curious about why you began your post by stating you respect psychologists?

 

[nancysinatra]

What does not make sense to me is this... Psychiatry is a medical specialty organized around diagnosing and treating symptoms, i.e., cognitive, emotional, and behavioural symptoms. Other medical specialities (generally speaking) are organized around the bodily organ they treat.

No, after 6 months of inpatient psych and constant psych call, I am convinced psychiatry is a specialty organized around redundant family meetings and having interns do gratuitous social work in the ER late at night. Things no surgery intern would be caught dead doing! And that probably no surgery et al program director would want them doing, either... ;-)

Seriously, psychiatry could be pared down in ways that are not being discussed here. People harp on how horrible "psychoanalysis" is, but I promise you, at least as a resident, it sure isn't "analysis" I'm doing when I'm sitting on the phone all day on hold. And from what I've seen of more experienced residents and attendings, the "social" part of the biopsychosocial model seems to get heavy emphasis at all levels.

For example, borderline patients most seem to benefit from learning skills to tolerate distress and control impulses (i.e., the behavioral level of analysis is most fitting here, even though the brain is involved in affect and impulse dysregulation). These types of patients might first be seen by the "brain doctors" to rule out medical causes of their symptoms (e.g., brain tumors, infections), and then sent to psychological therapists when they have been medically cleared. I believe this represents the best in patient care.

I have to say I think anyone can botch their work with borderline patients. Granted I'm no expert, but I have seen (in my limited time) psychologists make comments that were quite alarming. Like, female patients with multiple children through multiple partners come in, and the psychologist says, "borderline!" without even going through a differential. Then a male in the same situation appears, and the psychologist appears stumped. Plus, psychiatrists will always need to know therapy, and these patients will need to be seen in the hospital, so we have to be able to work with them.

But what do I know? I am pretty interested in personality disorders, and think it would be a privilege to help these patients if possible, but they're soon going away, I guess, with the new DSM.

 

[nancysinatra]

In the best of all possible worlds, I would like to see medical school
condensed to 3 years, with greater emphasis on clinical skills; and
psychiatric residency expanded to 5 years, with greater emphasis on
both medical/neurological science and psychotherapy training--plus
exposure to the "humanities" (philosophy, literature, etc.). I have also
suggested that a combined neurology-psychiatry residency may be
worth exploring, though this would have to be done very carefully, so
that neither field was simply "reduced" to the other.

I'm pretty sure that at least 25% of my medical school curriculum was useless empathy seminars. Absolutely every medical students loathes and vilifies these classes, does not remember one word, skips them whenever possible. Yet they are metastasizing and encroaching upon neuroscience, physical exam, pharmacology, radiology and all sorts of other useful courses! Get rid of them and med school could easily be 3 years!

I bet every specialty would welcome it. Good grief--if we have a tough time fitting psych residency into 4 years, look at neurosurgery. And think of those interventional cardiologists.

And none of them like empathy seminars either!!!

(However I would have liked more sessions on how to do a fundoscopic exam...)

 

[billypilgrim37]

All psychiatric disorders are not brain diseases... I don't disagree that all psychiatric conditions involve the brain to some degree, I just deny that they are diseases in the same sense as Huntington's disease, AZ disease, etc. For example, changing parenting styles doesn't treat seizure disorders in children but it does treat conduct disorder. Alzheimer's disease patients cannot be bribed into stopping their memory impairment, but substance use disorder patients stop using drugs with bribes (it's just called contingency management and it has loads of scientific research to promote it's use).

I think most of us on this forum will adamantly, vehemently, and lotsa-dramatic-adverb-edly disagree with you that a disorder having a heavy behavior component makes it not a brain disease. Brains aren't computers, and the hardware and software are simply not separate, and we will draw blood if you keep insisting that they in some way are. We wouldn't suddenly say that conditions for which physical therapy was the most appropriate treatment isn't suddenly a medical disorder. Orthopedic surgeons don't do physical therapy, but that is the most appropriate treatment for many orthopedic complaints.

Besides, do you know what absolutely destroys CBT for anxiety disorders? Benzodiazepines. There is nothing more effective on earth for an anxiety disorder than Klonopin 2mg TID. Except maybe 2mg QID. Or Xanax 5mg q2. Clearly, treating an anxiety disorder this way would be pure malfeasance, but what if Pfizer suddenly came out with a drug with all of the effects of a benzodiazepine without tolerance, withdrawal, and sedation? Aaron Beck would have to raise a white flag. That's not going to happen, but the fact that it theoretically could doesn't fit well with this arbitrary paradigm you propose.

How about OCD? OCD is clearly becoming more and more of a "brain disease," and won't even likely be in the "anxiety disorder" chapter of DSM-V. But the most effective intervention for it remains therapy. Where does it fit?

How about PTSD? All of the treatments for PTSD suck. Does that make it a brain disease? Or something else?

It's a really useless dichotomy, and it's not one that we're going to let you promote for one second without a knives-out challenge. Just because a behavioral intervention is the most appropriate intervention now and forever does not make the disorder less of a brain disorder. And just because schizophrenia is essentially a neurologic disorder does not make it any less of a mind disorder.

Maybe the reason why psychotherapy doesn't "cure" schizophrenia is because psychologists haven't been smart enough to come up with a psychotherapy that "cured" it. If you and your colleagues suddenly developed the wildly successful "psychosis reversal therapy," we wouldn't say that schizophrenia is suddenly no longer a "brain disorder."

We don't have to call these disorders "different" from each other to recognize that there are psychological and biological interventions that are beneficial to our patients, and sometimes one or the other is more appropriate, and often both of them are appropriate. And it's okay if we admit that most of don't have the time to complete both a medical program and a psychology program, because most of us are going to be looking at retirement about 35 years into our practices, and most of us will be dead 45 years after we start practicing. The MDs, at least, would like to pay off some of our loans before our children have to start paying back theirs.

Psychologists are better at some things than psychiatrists, psychiatrists are better at some things than psychologists. And some things we don't even try to do together. That's fine.

I would also propose that most of the mild-moderate depressive and anxiety disorders for which therapy alone is most appropriate never make it to a psychiatrist (in most communities). They get a script from their PCP, and maybe a referral for therapy. They probably stop taking the script after two weeks, and probably never go to therapy, and they make it just fine. Or they keep taking the under-dosed and illogically prescribed medication serving basically as an active placebo, and show up for therapy, and get better. But they usually don't wind up in the psychiatrist's office.

 

[billypilgrim37]

I'm pretty sure that at least 25% of my medical school curriculum was useless empathy seminars.

YES!

A much better strategy would be to continue to reward English majors and philosophy majors with medical school admissions. None of my classmates wanted to talk about William Carlos Williams with me, no matter how many times I photocopied poems and short stories for small groups.

 

[Ronpies]

.Hi, Folks--I've noticed that your discussion often enters the realm of philosophical issues that have preoccupied me since I was a resident; e.g., on the nature of "disease", what psychiatry deals with, etc. Just to stir the pot, may I throw out a few
notions to consider if you ever have a free moment:

1. Disease is properly predicated of (attributed to) persons, not "minds" or "brains".
2. Disease as a human experience (derived from dis-ease) is distinct from particular diseases (as pathoanatomic entities).
3. Psychiatry is interested in both the human experience of dis-ease, and its specific modes or instances (such as schizophrenia, Alzheimer's, bipolar illness, etc.).
4. The people to read on these matters are psychiatrist RE Kendell; philosophers Ludwig Wittgenstein and Edmund Husserl; and psychiatrist Nassir Ghaemi [cf. The Concepts of Psychiatry]
5. For a quick and dirty introduction to some of these issues, see
http://www.psychiatrictimes.com/display/article/10168/1402032

Enjoy! Psychiatry is a great field to think about....Best, Ron Pies MD

.

 

[AleksPsych]

I think most of us on this forum will adamantly, vehemently, and lotsa-dramatic-adverb-edly disagree with you that a disorder having a heavy behavior component makes it not a brain disease. Brains aren't computers, and the hardware and software are simply not separate, and we will draw blood if you keep insisting that they in some way are. We wouldn't suddenly say that conditions for which physical therapy was the most appropriate treatment isn't suddenly a medical disorder. Orthopedic surgeons don't do physical therapy, but that is the most appropriate treatment for many orthopedic complaints.

Besides, do you know what absolutely destroys CBT for anxiety disorders? Benzodiazepines. There is nothing more effective on earth for an anxiety disorder than Klonopin 2mg TID. Except maybe 2mg QID. Or Xanax 5mg q2. Clearly, treating an anxiety disorder this way would be pure malfeasance, but what if Pfizer suddenly came out with a drug with all of the effects of a benzodiazepine without tolerance, withdrawal, and sedation? Aaron Beck would have to raise a white flag. That's not going to happen, but the fact that it theoretically could doesn't fit well with this arbitrary paradigm you propose.

How about OCD? OCD is clearly becoming more and more of a "brain disease," and won't even likely be in the "anxiety disorder" chapter of DSM-V. But the most effective intervention for it remains therapy. Where does it fit?

How about PTSD? All of the treatments for PTSD suck. Does that make it a brain disease? Or something else?

It's a really useless dichotomy, and it's not one that we're going to let you promote for one second without a knives-out challenge. Just because a behavioral intervention is the most appropriate intervention now and forever does not make the disorder less of a brain disorder. And just because schizophrenia is essentially a neurologic disorder does not make it any less of a mind disorder.

Maybe the reason why psychotherapy doesn't "cure" schizophrenia is because psychologists haven't been smart enough to come up with a psychotherapy that "cured" it. If you and your colleagues suddenly developed the wildly successful "psychosis reversal therapy," we wouldn't say that schizophrenia is suddenly no longer a "brain disorder."

We don't have to call these disorders "different" from each other to recognize that there are psychological and biological interventions that are beneficial to our patients, and sometimes one or the other is more appropriate, and often both of them are appropriate. And it's okay if we admit that most of don't have the time to complete both a medical program and a psychology program, because most of us are going to be looking at retirement about 35 years into our practices, and most of us will be dead 45 years after we start practicing. The MDs, at least, would like to pay off some of our loans before our children have to start paying back theirs.

Of course the people in this forum will disagree with me, most of you are psychiatrists trained in the medical model. I expect disagreement. My view is much more nuanced than I think is coming across. Of course the brain is involved in all psych disorders, but the issue of diseased brains is where we disagree.

Benzos absolutely destroy CBT? Show me the journal articles that show that please. Ive read dozens of articles that clearly show CBT is better in the long-term, and equally or more better in the short-term than any medication. But if you have references to show me, I'd like to see them.

All treatments for PTSD suck? Psychologists not being smart enough? You just turned this argument into an immature one so I won't comment any further. Sorry.

 

[snarfer]

The definition of disease that you give in this post is the exact same definition I gave in the post you referenced. However, the definition you gave in an earlier post was not the same.

All psychiatric disorders are not brain diseases. While it is true that the pathophysiology of many medical disorders is unknown (btw, this is a typical argument that psychiatrists make to validate the medicalization of all the conditions they treat), no other speciality consists of as many disorders of unknown pathophysiology as psychiatry does. I don't disagree that all psychiatric conditions involve the brain to some degree, I just deny that they are diseases in the same sense as Huntington's disease, AZ disease, etc. but substance use disorder patients stop using drugs with bribes (it's just called contingency management and it has loads of scientific research to promote it's use).

If I can be a psychologist for one second... I'm curious about why you began your post by stating you respect psychologists?

Based on your other posts, you seem to imply that diseases are classified as impaired functions in addition to known structural abnormalities. The two definitions I provided, which basically stated the same thing, were meant to counter your incorrect assumptions regarding mental health diseases.

You seem to imply that psychiatrists try to medicalize mental health illness for our own gains. This is another incorrect assumption or allegation as after years in medical school and internship in various other medical specialties, we all know that there is much uncertainy regarding the etiologies of illness throughout medicine and not just in mental health.

Do bribes work all the time with substance users? There are numerous studies showing genetics and neural circuit dysfunctions in substance use which behavioral therapy can help somewhat. Another very difficult disease to treat.

Regarding your last point, I find it fascinating that psychologists, with minimal or zero medical training, often make generalize statements regarding the topic.