Do we have a point?

[DD214_DOC]

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This isn't an existential question. After a year of internship, I'm starting to have doubts about choosing this specialty. I still enjoy it for the most part, but a few things make me question its long-term viability.

1) Psychologist do therapy better. Now, many states have Rx rights in the works for them. What would be our point once the PsyD/PhD can do both?

2) On the consult service, nobody ever bothers to read our notes. Nobody follows our recs. What's the point?

3) Safety Assessment. Anyone can buy Shea's book and learn how to do this just as well as we can. In fact, a few ER docs took a class and no longer consult us unless a patient is psychotic or manic, or definitely meets criteria for high-risk and requires admission.

Maybe this is just intern year blues?

 

[atsai3]

This isn't an existential question. After a year of internship, I'm starting to have doubts about choosing this specialty. I still enjoy it for the most part, but a few things make me question its long-term viability.

1) Psychologist do therapy better. Now, many states have Rx rights in the works for them. What would be our point once the PsyD/PhD can do both?

That's why psychologists have been fighting tooth-and-nail, and psychiatrists fighting tooth-and-nail against them, for prescribing privileges.

3) Safety Assessment. Anyone can buy Shea's book and learn how to do this just as well as we can. In fact, a few ER docs took a class and no longer consult us unless a patient is psychotic or manic, or definitely meets criteria for high-risk and requires admission.

Maybe this is just intern year blues?

Sounds like you are at one end of the extreme. The other extreme, which drives many residents to want to gouge their eyeballs out, is when the ER docs do not bother to learn about safety assessment and speed-dial psych for every hungry, sandwich-seeking homeless or marginally housed person who walks through the door endorsing suicidal ideation. Pick your poison, I guess.

 

[Doc Samson]

This isn't an existential question. After a year of internship, I'm starting to have doubts about choosing this specialty. I still enjoy it for the most part, but a few things make me question its long-term viability.

1) Psychologist do therapy better. Now, many states have Rx rights in the works for them. What would be our point once the PsyD/PhD can do both?

2) On the consult service, nobody ever bothers to read our notes. Nobody follows our recs. What's the point?

3) Safety Assessment. Anyone can buy Shea's book and learn how to do this just as well as we can. In fact, a few ER docs took a class and no longer consult us unless a patient is psychotic or manic, or definitely meets criteria for high-risk and requires admission.

Maybe this is just intern year blues?

Sure sounds like the intern blues. You could probably find 3 similar points for any specialty you'd care to name. On a point by point basis:

1) Maybe they can, maybe they can't (this is being hotly and occasionally civilly debated on another thread). Either way, you should be able to practice psychotherapy by the end of your training - if you like it, you should so it.

2) Sounds like your working on a fairly ineffective consult service. If a service builds a reputation in the hospital, folks tend to be much more ready to take your recs. I (and many others) have questioned the wisdom of having anyone below a PGY-3 working on a CL service since it takes a certain degree of confidence in your own area of practice before you can effectively make others listen to you.

3) Sure, they could do this, and they might - until there's one bad outcome and the malpractice attorney asks "So, doctor, you had a psychiatrist to consult on this case, but you chose not to... could you tell me why you think you are qualified to practice as a psychiatrist?" As Atsai said, you want to find the happy medium where folks are consulting you on the folks they should, but not on every "I might as well just die!" statement that rolls through the hospital.

One of the coolest things about psychiatry is how many different types of practice you can find. Start looking at some niche areas and see what fits for you.

 

[Manicsleep]

This isn't an existential question. After a year of internship, I'm starting to have doubts about choosing this specialty. I still enjoy it for the most part, but a few things make me question its long-term viability.

1) Psychologist do therapy better. Now, many states have Rx rights in the works for them. What would be our point once the PsyD/PhD can do both?

2) On the consult service, nobody ever bothers to read our notes. Nobody follows our recs. What's the point?

3) Safety Assessment. Anyone can buy Shea's book and learn how to do this just as well as we can. In fact, a few ER docs took a class and no longer consult us unless a patient is psychotic or manic, or definitely meets criteria for high-risk and requires admission.

Maybe this is just intern year blues?

1) You can learn therapy as well as anyone and if you apply your medical knowledge to your psychotherapy, you will be the better therapist.

2) I have very good relationships with the physicians who consult me. Although I don't mind seeing PGY1/2s on a CL service, there should be a senior running the service.

3) EBM is the foundation and vital to the field of medicine. However, clinical judgment is based on clinical experience because the evidence is often based on narrow criteria and it is your job to understand its limitations.

 

[whopper]

1) Psychologist do therapy better. Now, many states have Rx rights in the works for them. What would be our point once the PsyD/PhD can do both?

It all depends on the individual. If you want to ask me which training is likely better as a curriculum with psychotherapy, I'd tell you I've been more impressed with Counseling programs vs. Psychiatry or Psychology, yet despite what I've just written, I've never seen a trend that makes one type much better than the other.

The only real large determining factors IMHO as to what made a good psychotherapist was if the person gave a damn, the person was a good listener, and treated each case as something where they'd have to do a lot of critical thinking. The problems with every field is no matter how good the curriculum is, you're going to have people who don't follow those 3 requirements. The only exception to this was if the person required a specific type of therapy (e.g. DBT) and the therapist was not trained in it.

Maybe this is just intern year blues?

Possibly. It's also possible there's problems in your particular program that aren't being addressed. (I think I'd also chalk that up as intern blues as well). Several attendings dump work on residents, not for the sake of learning but for the sake of solely making their own lives easier. Several programs use residents as cheap labor to so they don't have to hire social workers.

I agree with Doc Samson's points. Where I did residency, there were ineffective attendings, and the other departments were able to sniff them out. As a resident, you're working under the attending who for all intents and purposes may be mediocre at what they do. By the time I was a PGY-IV, a few attendings from other departments were trying to get me to work as a consultant at their private practice, telling me they never would have given the offer to some of the attendings I had to kowtow to for years. As a chief resident, the department secretary sometimes told me that the department chair was being driven nuts by some attendings who she thought were even worse than residents.

Safety Assessment. Anyone can buy Shea's book and learn how to do this just as well as we can.

Disagree. There's data showing that actuarial and clinical data is superior to either by itself. There's also data that positive signs of psychosis is a risk factor for violence but negative signs are not. You need a mental health professional for that, and in that regard we are better than other types of M.D.s

 

[nitemagi]

Excellent posts by my colleagues so far, and I agree with all of them.

I tend to think of the field (unfortunately) as a little pond. Make yourself a big fish, in that if you see the mediocrity in which certain aspects of the field are practiced, then that is an opportunity for you to become better than that and distinguish yourself. Whopper describes his own development in a similar vein.

You're at a turning point where you can settle into the idea that your existence feels purposeless, and just roll with that, or you can see it as a call to arms to make yourself better. Whatever better means for you. Finding your niche, knowing a body of literature better than attendings, developing better clinical acumen, advanced psychopharm training, learning a particular psychotherapy well, etc.

And while psychologists may portray the image that they're superior in psychotherapy, I am aware of no data that actually shows this. Psychiatrists have vastly more hours of patient exposure, more severe and broader psychopathology exposure, and broader environments (inpt, emergency, outpt). Psychologists spend much more time in the classroom and learning stats/research. The point being that if you want to do psychotherapy, you can. If you feel your program isn't going to teach it well enough, pursue it on your own (workshops, books, supervision, etc). And don't be limited to the idea that everything has to be mastered by the end of residency. Lifelong learning is exactly that - lifelong.

 

[loveoforganic]

This thread is going to go places

 

[Manicsleep]

RE: Intern blues. I am not trying to diagnose you because I don't know you but your post reminds me of Beck's cognitive triad.

You (the psychiatrist) are worthless.
Your environment (the consult teams) is unfair.
Your future (Psychiatry's) looks bleak and hopeless.

 

[Majesty]

You (the psychiatrist) are worthless.
Your environment (the consult teams) is unfair.
Your future (Psychiatry's) looks bleak and hopeless.

That was pretty much me at about this time in intern year. My salvation didn't come until the APA convention where the program paid for me to go.

 

[peppy]

This isn't an existential question. After a year of internship, I'm starting to have doubts about choosing this specialty. I still enjoy it for the most part, but a few things make me question its long-term viability.

1) Psychologist do therapy better. Now, many states have Rx rights in the works for them. What would be our point once the PsyD/PhD can do both?

This issue is really no different than how NPs, PAs, and CRNAs are trying to make in-roads in other specialties (a lot of people do feel that the battle is already lost for anesthesia and family practice in this regard).
I've always hoped that if we do end up in a system where psychologists are doing most general psychiatry,then the role of a psychiatrist might be shifted to focus more on the more medically complex and challenging cases. Perhaps more focus in the training on things like managing pregnant/post partum women with mental illness, neuropsychiatry, etc.
Maybe feeling this way just is a sign that GENERAL psychiatry isn't for you and you should be thinking about if any of the fellowships appeal to you. Even if you're not interested in any of the psych-only fellowships, maybe you were meant to go into something like Pain Medicine or Palliative Care.

 

[kugel]

maybe you were meant to go into something like Pain Medicine or Palliative Care.

Or maybe sleep medicine, or addiction, or (please, please, PLEASE go into) geriatric psych. We're going to need them so badly (and probably pay them so well) into the next several decades.

 

[DD214_DOC]

I am glad to see that this thread has spurred some discussion.

I don't mind the "touchy feely" side of psychiatry, but I think faculty who only utilize this method are at a disadvantage both clinically and professionally. My program is very, very heavy on psychodynamic psychotherapy and I get the sense that Psychiatry is moving away from this and more towards the biological/neuropsych model. Or at least I feel that it *should* be. Each modality has its place and, in my opinion, limited use, but to attempt to apply one specific theory to every single patient and every presentation seems a bit ludicrous to me; not everyone has issues because their mommy didn't love them.

It seems the more I learn, the more disenfranchised I become. The use of antipsychotics for delirium is a great example. It's not that complicated, and we don't recommend them really for the antipsychotic effect (which takes weeks to actually do anything, for those who don't know); we simply recommend them for delirium or acute psychosis to snow the patient due to the sedative properties. The "advanced" psychopharm is really just knowing the side effect profiles and receptor affinities for the various psychotropics, which can easily be found in a chart.

After seeing the "revolving door" patients for months, I can really only recall two people who actually present in crisis, received treatment, continued in follow-up and is actually doing well. The others just repeat the same cycle over and over and over. The paradigm of how SSRIs work is completely contradicted by how depression and anxiety are treated in Europe (with SSREs!) and begs the question if we really know what we're doing at all.

Maybe this is the same phenomenon that happens in early medical education, where you learn enough to think things are so simple until you learn more and realize they aren't.

As far as fellowships, it's unlikely I will remain in general psychiatry. I have been considering addictions, forensics, psychosomatic medicine/geri psych, neuropsychiatry, and sleep medicine.

 

[Doc Samson]

It seems the more I learn, the more disenfranchised I become. The use of antipsychotics for delirium is a great example. It's not that complicated, and we don't recommend them really for the antipsychotic effect (which takes weeks to actually do anything, for those who don't know); we simply recommend them for delirium or acute psychosis to snow the patient due to the sedative properties.

No, we don't. The goal of effective delirium management should be a calm but wakeful patient that is able to participate in their treatment. We use neuroleptics in delirium because our understanding of the condition centers on a relative state of hyperdopaminergia and hypocholinergia. Thus, our job is to block dopamine and optimize acetylcholine. We don't have any drug with a reasonable safety profile (so no physostigmine) that increases acetylcholine rapidly enough to be of any use in delirium, so we need a drug that blocks dopamine without further inhibiting cholinergic transmission. That's why we've used IV Haldol for going on 4 decades now. Powerful dopamine blockade, minimal anticholinergic profile. Since dopamine potentiates glutamate, not only are you stopping the hallucinations of delirium, you're also stopping the agitation. Recent studies have also raised the issue of Haldol's sigma-1 antagonism (a property that other neuroleptics don't have) as neuroprotective - so as well as minimizing the toxic effects from the neurons that have already died, you're preventing other neurons from dying.

Snowing patients isn't fun, and it sure isn't rewarding. Saving neurons can be fun, and it is rewarding. It's all in the frame - but you need to know WHY you're doing what you're doing to frame it correctly.

 

[DD214_DOC]

No, we don't. The goal of effective delirium management should be a calm but wakeful patient that is able to participate in their treatment. We use neuroleptics in delirium because our understanding of the condition centers on a relative state of hyperdopaminergia and hypocholinergia. Thus, our job is to block dopamine and optimize acetylcholine. We don't have any drug with a reasonable safety profile (so no physostigmine) that increases acetylcholine rapidly enough to be of any use in delirium, so we need a drug that blocks dopamine without further inhibiting cholinergic transmission. That's why we've used IV Haldol for going on 4 decades now. Powerful dopamine blockade, minimal anticholinergic profile. Since dopamine potentiates glutamate, not only are you stopping the hallucinations of delirium, you're also stopping the agitation. Recent studies have also raised the issue of Haldol's sigma-1 antagonism (a property that other neuroleptics don't have) as neuroprotective - so as well as minimizing the toxic effects from the neurons that have already died, you're preventing other neurons from dying.

Snowing patients isn't fun, and it sure isn't rewarding. Saving neurons can be fun, and it is rewarding. It's all in the frame - but you need to know WHY you're doing what you're doing to frame it correctly.

Are you really getting a significant antidopaminergic effect in the time frame of hours - days? From what I have read/been taught, this is very unlikely. My understanding, besides the DA/ACh stuff, is that the "incidental" sedative properties of antipsychotics from their antihistaminic profiles sedate the patient enough to control the behavior until an etiology for the delirium is found and it is able to be addressed and resolve.

 

[Doc Samson]

Are you really getting a significant antidopaminergic effect in the time frame of hours - days? From what I have read/been taught, this is very unlikely. My understanding, besides the DA/ACh stuff, is that the "incidental" sedative properties of antipsychotics from their antihistaminic profiles sedate the patient enough to control the behavior until an etiology for the delirium is found and it is able to be addressed and resolve.

With IV Haldol? Minutes to hours. How soon can you see an acute dystonia after neuroleptic administration? Why would management of delirium take significantly longer? Animal studies show Haldol only effects the histamine receptors with chronic, high dose administration.

 

[Manicsleep]

It seems the more I learn, the more disenfranchised I become. The use of antipsychotics for delirium is a great example. It's not that complicated, and we don't recommend them really for the antipsychotic effect (which takes weeks to actually do anything, for those who don't know); we simply recommend them for delirium or acute psychosis to snow the patient due to the sedative properties. The "advanced" psychopharm is really just knowing the side effect profiles and receptor affinities for the various psychotropics, which can easily be found in a chart.

Consult psychiatry is a very hard thing to learn. Its even harder to learn well. You will need charts and electronic brains etc but most of all you need experience and solid medical understanding. Especially of non psychiatric issues.

After seeing the "revolving door" patients for months, I can really only recall two people who actually present in crisis, received treatment, continued in follow-up and is actually doing well. The others just repeat the same cycle over and over and over. The paradigm of how SSRIs work is completely contradicted by how depression and anxiety are treated in Europe (with SSREs!) and begs the question if we really know what we're doing at all.

I have found that the 80/20 rule is true in most of inpatient medicine. YOu successfully treat about 20% (if you are lucky) and 80% just keep coming back. In addition, there are some things that are progressive and the best you can hope for is to slow the progression down...my advice just keep it in perspective.

Maybe this is the same phenomenon that happens in early medical education, where you learn enough to think things are so simple until you learn more and realize they aren't.

👍

Thats why I find it particularly scary when people think they can do what attendings can do after what is less than an MS1 education.

 

[Dermologue]

So the take home message of this thread is that psychiatry is harder than the other specialties because it takes more years of experience in order to reach *that* confidence level. Ultimately, once that point is reached, the satisfaction level tends to spike exponentially relative to other fields, yes? It seems shrinks are a happy bunch...
There was an article out there about psych being the most difficult specialty...And that difficulty was not attributed to "difficult patients," i.e. your run-of-the-mill patient that IM might consider difficult, if I recall correctly.

 

[dl2dp2]

With IV Haldol? Minutes to hours. How soon can you see an acute dystonia after neuroleptic administration? Why would management of delirium take significantly longer? Animal studies show Haldol only effects the histamine receptors with chronic, high dose administration.

Ted Stern @ MGH told me that IV Haldol does NOT give acute dystonia even at extremely high doses. I think the hypothesis that delirium has anything to do with dopamine is very controversial, and the data for efficacy of Haldol in treatment is also very dubious. The canonical teaching now seems to (to me) be that delirium has no effective pharmacologic treatment.

 

[Halverson]

Ted Stern @ MGH told me that IV Haldol does NOT give acute dystonia even at extremely high doses. I think the hypothesis that delirium has anything to do with dopamine is very controversial, and the data for efficacy of Haldol in treatment is also very dubious. The canonical teaching now seems to (to me) be that delirium has no effective pharmacologic treatment.

Don't know what else to say aside from I've seen 3 patients on IV Haldol get dystonia in the past 3 years. I realize the plural of "anecdote" isn't "data," but that's surprising to hear.

Likewise, data on haldol's efficacy in regards to delirium management is pretty good - a basic pubmed search shows pretty convincing evidence it reduces overall delirious days. Is 0.5 of Haldol gonna make a gal on a rotaprone bed and versed/ativan drips going through alcohol withdrawal not delirious? No. Will it overall help delirious patients recover faster? Yes.

 

[billypilgrim37]

Every time you convince a nurse to give IV Haldol instead of Ativan to people over 65 an angel gets his wings.

"I don't understand it! He gets upset, so I give him some Ativan! Then he gets out of bed and starts thrashing and won't sit down, so I give him some more Ativan, and then all the sudden he's urinating on the sitter, and we call security and he starts speaking in these other languages, and I give him more Ativan, and it won't calm him down! You need to take him to the psych unit where he belongs! And he was such a nice old man last week before the surgery..."

 

[DD214_DOC]

Every time you convince a nurse to give IV Haldol instead of Ativan to people over 65 an angel gets his wings.

"I don't understand it! He gets upset, so I give him some Ativan! Then he gets out of bed and starts thrashing and won't sit down, so I give him some more Ativan, and then all the sudden he's urinating on the sitter, and we call security and he starts speaking in these other languages, and I give him more Ativan, and it won't calm him down! You need to take him to the psych unit where he belongs! And he was such a nice old man last week before the surgery..."

Nurses have nothing to do with it. It's the internists. I see it time and time again and I still can't figure out why they don't know this?

 

[nitemagi]

Nurses have nothing to do with it. It's the internists. I see it time and time again and I still can't figure out why they don't know this?

Some do.

I ask myself why is midazolam still a common part of the surgical admission order set?

 

[Doc Samson]

Ted Stern @ MGH told me that IV Haldol does NOT give acute dystonia even at extremely high doses. I think the hypothesis that delirium has anything to do with dopamine is very controversial, and the data for efficacy of Haldol in treatment is also very dubious. The canonical teaching now seems to (to me) be that delirium has no effective pharmacologic treatment.

As much respect as I have for Ted, I'll go with IV Haldol very seldomly causes dystonia.

The acetylcholine/dopamine hypothesis of delirium is just that - a hypothesis. As hypotheses go, though, it's really not all that controversial at all. Would agree that there is no definitive pharmacologic treatment of delirium - the meds limit the symptoms and prevent further neuronal death (by sigma-1 antagonism and inhibiting the potentiation of glutamate) to buy us time to identify and treat the underlying cause.

 

[billypilgrim37]

Nurses have nothing to do with it. It's the internists. I see it time and time again and I still can't figure out why they don't know this?

Given both orders, nurses outside of the ICU will frequently use the Ativan and ignore the Haldol. They will also wake up the cross-covering doctor for Ativan orders when there is no standing ativan order but there is a prn Haldol IV order, and the cross-cover really doesn't care.

 

[Sneezing]

Regarding point 1, I have no concerns of psychologists replacing us. Just because you give them a prescription pad doesn't mean they'll know what to do with it. Why would you expect them to be more capable then a PA or NP? They certainly won't get any where near the training the midlevels get. And as you pointed out not every illness is rooted in psychodynamics. Some one else noted they don't get the breadth or severity of clinical exposure we do.

It also doesn't look good for psychologists when patient advocacy groups are against this.

 

[SpiritiualDuck]

The point about who is better at therapy is relative and beyond generalizations regarding initials after your last name. Like others have said, it's about the person, the relationship; it's about you.

At my program, I do get the impression from some of the psychology interns that they feel or what to believe that they are better equipped to do therapy. I think it's driven by an insecurity about what they don't know more than what they know.

That said, I'm confident in my abilities and I have seen good therapy done by psychiatrist, psychologists, and social workers. And bad therapy done by all those degrees too.

Personally, I like the one provider model where I'm capable of doing therapy and med management. And when we have group meetings/consults and a psychologist or social worker makes med recommendations...I bristle. We have some shared didactics and it works well.

Also, as an intern, you just haven't seen much other than acuity of inpatient and the ED. 3rd year will change your perspective in many ways.

 

[CaMD]

3) Safety Assessment. Anyone can buy Shea's book and learn how to do this just as well as we can. In fact, a few ER docs took a class and no longer consult us unless a patient is psychotic or manic, or definitely meets criteria for high-risk and requires admission.




I'm not sure why you're complaining about this. This is my idea of heaven.

 

[digitlnoize]

Do we have a point? Yes. People aren't getting any less crazy. Mental illness isn't going away anytime soon. Drugs can help, but even when they don't, psychiatrists have a better understanding of how a patients mental illness interacts with their medical conditions.

 

[DD214_DOC]

Here's a good one I will throw out there. Our ER staff during the day rotate every few days. A clinical psychologist (PhD) is in this rotation. I have been down to the ER to evaluate and dispo a patient supervised solely by a PhD.

While I have no contention of being supervised by a clinical psychologist for non-medical, non-pharmacologic issues, I wonder how this is even legal. Whose medical license am I operating under during this time? How am I not practicing medicine independently with a restricted license since I am an intern? Somehow this doesn't seem "right" and I feel it's an issue I should raise with the program. While I don't know the laws regarding this all that well, I feel if there was a bad outcome I would be pretty screwed since I was not operating under another physician's MEDICAL license.

 

[Doc Samson]

Here's a good one I will throw out there. Our ER staff during the day rotate every few days. A clinical psychologist (PhD) is in this rotation. I have been down to the ER to evaluate and dispo a patient supervised solely by a PhD.

While I have no contention of being supervised by a clinical psychologist for non-medical, non-pharmacologic issues, I wonder how this is even legal. Whose medical license am I operating under during this time? How am I not practicing medicine independently with a restricted license since I am an intern? Somehow this doesn't seem "right" and I feel it's an issue I should raise with the program. While I don't know the laws regarding this all that well, I feel if there was a bad outcome I would be pretty screwed since I was not operating under another physician's MEDICAL license.

😱😱😱

You're right - this is very, very wrong.

 

[nitemagi]

Here's a good one I will throw out there. Our ER staff during the day rotate every few days. A clinical psychologist (PhD) is in this rotation. I have been down to the ER to evaluate and dispo a patient supervised solely by a PhD.

While I have no contention of being supervised by a clinical psychologist for non-medical, non-pharmacologic issues, I wonder how this is even legal. Whose medical license am I operating under during this time? How am I not practicing medicine independently with a restricted license since I am an intern? Somehow this doesn't seem "right" and I feel it's an issue I should raise with the program. While I don't know the laws regarding this all that well, I feel if there was a bad outcome I would be pretty screwed since I was not operating under another physician's MEDICAL license.

All I'm going to say is I know what you mean. Sadly.

 

[whopper]

You should be able to raise this issue in the program. The GME should also be made aware. Now that's all things being equal, and assuming your in the type of program where your head doesn't get cut off for asking things you should be asking.

And as we all know, not every program is like that.

 

[Mattchiavelli]

I'm taking a medical therapeutics course right now as an MS4 and we've been talking a lot about developing our "personal formulary"- basically the idea that in our specialties we are going to have a smaller set of drugs that we use constantly and know backwards, forwards, in and out regarding both data and clinical use. Psychiatrists are second to none in knowing the nuances of behavior modifying medications and being engaged with the literature to go beyond the "Haldol= nap + parkinsons, depression=any ssri, trazodone=priapism" that a lot of GPs are running on. And regarding psychologists prescribing, you will have more knowledge of pharmacological principles and pathophysiology that is pertinent to drug distribution, metabolism, interaction, etc.

The problem I have with physician extenders getting larger scopes of practice is that I see them taking the easy visits away from docs who use them to balance their workloads- IE the 5 minute coumadin adjustment that balances the 25 minute visit from granny smith who is on 15 meds and has a chronic disease of every organ system.

I also want to say I have a parent that was helped GREATLY by a good psychiatrist. Try to focus on the patients you are truly helping, someone is surely grateful for the care you provide.

 

[DD214_DOC]

You should be able to raise this issue in the program. The GME should also be made aware. Now that's all things being equal, and assuming your in the type of program where your head doesn't get cut off for asking things you should be asking.

And as we all know, not every program is like that.

So I've raised this issue a couple of times and everyone seems to simply be parroting, "It's ok for a PhD to supervise us because they have a license". I've pointed out multiple times that their license is not the same as our license, but constantly am told, "It's ok because they have a license and we can staff psychiatric stuff with them".

My gut tells me that this is NOT the core issue, the core issue is that a PHYSICIAN is being supervised and staffing cases with someone else who is NOT A PHYSICIAN.

I have yet to look at the laws so I don't have any actual facts to go by other than what I have stated. Any backup or links would be useful.

 

[Majesty]

Anonymously report it to your GME office.
CC it to the ACGME, your chairman and your program director. Include facts and not opinion. Do it Monday morning.

 

[Manicsleep]

Here's a good one I will throw out there. Our ER staff during the day rotate every few days. A clinical psychologist (PhD) is in this rotation. I have been down to the ER to evaluate and dispo a patient supervised solely by a PhD.

While I have no contention of being supervised by a clinical psychologist for non-medical, non-pharmacologic issues, I wonder how this is even legal. Whose medical license am I operating under during this time? How am I not practicing medicine independently with a restricted license since I am an intern? Somehow this doesn't seem "right" and I feel it's an issue I should raise with the program. While I don't know the laws regarding this all that well, I feel if there was a bad outcome I would be pretty screwed since I was not operating under another physician's MEDICAL license.

Clarify in writing with the higher ups, use email. Who specifically is telling you this is ok?

You may try to get some advice from your district-APA education committee or even the government relations committee. I would agree with contacting ACGME. Be careful, you don't want to get burned, so use some tact. Explain why you are concerned, relay the dangers to patient care as well as the poor quality of education you would be receiving. You may want to get risk management involved as well. Once the lawyers get into this, its bad news all around.

 

[Manicsleep]

So I've raised this issue a couple of times and everyone seems to simply be parroting, "It's ok for a PhD to supervise us because they have a license". I've pointed out multiple times that their license is not the same as our license, but constantly am told, "It's ok because they have a license and we can staff psychiatric stuff with them".

My gut tells me that this is NOT the core issue, the core issue is that a PHYSICIAN is being supervised and staffing cases with someone else who is NOT A PHYSICIAN.

I have yet to look at the laws so I don't have any actual facts to go by other than what I have stated. Any backup or links would be useful.

Well, that depends on how it is set up. Is the ER physician being counted as the physician? Is a physician being labeled as the go to person but just not present such as what happens with NPs or PAs?

These may all be issues for concern and you can voice them with the ACGME.

https://www.acgme.org/acWebsite/resInfo/ri_formalcomplaint.asp

I would not do a formal complaint but just ask advice initially. You can call them and ask what you should do initially.

 

[kugel]

So I've raised this issue a couple of times and everyone seems to simply be parroting, "It's ok for a PhD to supervise us because they have a license". I've pointed out multiple times that their license is not the same as our license, but constantly am told, "It's ok because they have a license and we can staff psychiatric stuff with them".

My gut tells me that this is NOT the core issue, the core issue is that a PHYSICIAN is being supervised and staffing cases with someone else who is NOT A PHYSICIAN.

I have yet to look at the laws so I don't have any actual facts to go by other than what I have stated. Any backup or links would be useful.

Do you feel comfortable telling us what state this in?

 

[Manicsleep]

Here is an excerpt from the ACGME that delineates just what supervision means. This is from 2010 update.



Levels of Supervision. In the development and description of systems to oversee resident supervision and graded authority and responsibility, each program must use the following classification of supervision.

1. Direct Supervision —The supervising physician is physically present with the resident and patient
2. Indirect Supervision:
   1. Direct supervision immediately available – The supervising physician is physically within the confines of the site of patient care, and immediately available to provide Direct Supervision
   2. Direct supervision available – The supervising physician is not physically present within the confines of the site of patient care, is immediately available via phone, and is available to provide Direct Supervision

I think that without contacting the ACGME, that is the best you are going to find. Now, can you have direct psychologist supervision with indirect supervision by a physician? Sure. You just need to know who the real boss is and they need to be available to provide supervision when needed either physically or by phone.

 

[whopper]

I hate saying this but if you're getting the types of responses you're getting, this is signally to me that your program doesn't seem to know WTF is going on or caring.

This is a reason why I went into a fellowship. I too thought some things could've been a heck of a lot better in some ways where I did training. While I was for the most part happy where I trained, I knew a lot of the answers I was getting were because the attendings didn't know or cared. While that doesn't exactly make the program sound so good, I've noticed this problem in several places. Doing fellowship allowed me to see how another institution handled things.

It may actually be that it's very inappropriate that the psychologist is doing what he is doing, and that actually bringing this up to the GME will just tick of people in the psychiatry dept instead of what it should actually be doing....fixing something that could be in violation of the rules.

Like what was said above, just report the facts. The less you bring in your own frustrations about this, the less the dung may fly back at you.

 

[nitemagi]

I acknowledge there are political issues that can be at play, and it's tough to rock the boat in your program, especially as an intern. An alternative approach is to file an anonymous (or not anonymous) report with the state psychology board, stating that this psychologist is practicing outside the scope of his license.