Family Medicine acting as a Psychiatrist

[MADD!!!]

Hey Everyone,

So I understand that FM physicians get training in Psychiatry as part of their residency. With this, to what extent are they trained to deal with Psychiatric patients compared to a Psychiatrist? For example, can a FM physician treat patient A for general medicine, then have pt. B come in for a Psych Diagnostic eval or a pt. visit w/ 30 min of Psychotherapy?

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[SourceOfDenial]

FM residency doesn't have a psych component typically. Having behavioral health curriculum is a requirement, but there is no mandated service requirement on a primary psychiatric floor or in a clinic.

Short of it is they see more psychiatric illnesses than psychiatrists with no training over their careers.

As a FM doc you won't have a 30 min spot for psychotherapy, ever.

 

[MADD!!!]

FM residency doesn't have a psych component typically. Having behavioral health curriculum is a requirement, but there is no mandated service requirement on a primary psychiatric floor or in a clinic.

Short of it is they see more psychiatric illnesses than psychiatrists with no training over their careers.

As a FM doc you won't have a 30 min spot for psychotherapy, ever.

It still kind of confuses me. I ask b/c I see FM physician also get trained in Ob/Gyn to the point where they can deliver babies and perform well-women exams. For pediatrics they get training, so they are allowed to treat children (while IM legally cannot). I have seen from some residency sites that they do provide Psychiatry training as well, but wondering how the training translates to what a FM physician can perform clinically in the realm of Psychiatry. Is it just to the point of if during a physical exam or patient check-up, a patient states they are depressed, so the physician has the right to prescribe anti-depression medications? something of that nature?

 

[splik]

Psychiatry is not a required FM rotation so there are lots of family medicine docs who received no further training in psych after their 3rd yr clerkship. Obviously there are some family physicians who are very interested in psychological medicine, run balint groups, are able to skillfully deploy motivational enhancement techniques and brief cognitive-behavioral interventions as well as understanding psychodynamic factors in the consultation and managing family dynamics and do well as managing depression, anxiety, problems of living, somatization, abnormal illness behavior, and substance use disorders, but those people are the exception to the rule and have gone out of their way to focus on working with such patients and get additional training. they may be better than psychiatrists at doing what they do. But most FM docs have no training and no interest in working with the mentally ill (despite the fact that 70% of mental disorders are treated in primary care) and prescribe everyone xanax.

my opinion is that primary care physicians should be dealing with a different level of mental illness than psychiatrists. severe depressive illness, personality disorder, eating disorders, PTSD, bipolar, psychosis, complex comorbidities, treatment-refractory states are mostly beyond the scope of primary care alone (unless patients are stable). PCPs should be more than capable of dealing with depression (up to 3 failed trials of treatment), anxiety, starting initial treatment for psychosis/bipolar and referring on, and basic management of substance use disorders (e.g. managing alcohol withdrawal, suboxone, prescribing MAT). of course there is huge variability in what they can do.

 

[TexasPhysician]

It still kind of confuses me. I ask b/c I see FM physician also get trained in Ob/Gyn to the point where they can deliver babies and perform well-women exams. For pediatrics they get training, so they are allowed to treat children (while IM legally cannot). I have seen from some residency sites that they do provide Psychiatry training as well, but wondering how the training translates to what a FM physician can perform clinically

All physicians are first trained to be physicians, but most of us understand the complexity of medicine enough to maintain our practice within our scope of training. Also malpractice companies don’t particularly like it when we venture away from our training.

There is nothing legally that prevents me from opening up an acne clinic, joint injection center, or even having my own primary care clinic.

 

[nexus73]

There is a broad spectrum of what different FM doctors are comfortable/capable of treating. Some want absolutely nothing to do with mental health beyond low dose SSRI for mild depression/anxiety. Some are forced to be competent because there aren't enough psychiatrists to refer harder patients on to see. Some are completely incompetent but extremely over confident and put their borderline patient on 10 meds but never refer them to psychotherapy (also see this from psychiatrists sometimes too).

 

[MADD!!!]

All physicians are first trained to be physicians, but most of us understand the complexity of medicine enough to maintain our practice within our scope of training. Also malpractice companies don’t particularly like it when we venture away from our training.

There is nothing legally that prevents me from opening up an acne clinic, joint injection center, or even having my own primary care clinic.

I don't mean it in any way to say that a FM physician do what a Psychiatrist does. But like @splik said dealing with the general, low-complexity type cases because many PCP's are prescribing anti-depressants and anti-anxiety medications as well as giving refills on medications that a Psychiatrist originally prescribed. I guess this might be a better question for the FM thread? I'm not sure because with FM's limited training in so many different fields as part of their residency, it's hard to decipher (for me at least) where the boundary of their scope should be in each field compared to the experts of that field.

Also looking now, I see curriculum varies between programs as well: https://keck.usc.edu/family-medicin...residency-program/rotation-schedule-overview/

In this program, residents do a 1-month Psych ER rotation during second year as well as various other trainings. But other FM residencies have no formal Psych rotation involved.

 

[Stagg737]

With this, to what extent are they trained to deal with Psychiatric patients compared to a Psychiatrist?

In my limited experience, not much formally if at all. Imo, every physician should know how to identify and treat run-of-the-mill depression or anxiety, but the number of FM/IM/Peds attendings or residents I've worked with who can't even accurately describe what bipolar disorder is frustrates me. I also think a lot of the non-psych attendings I've worked with over-prescribed or inappropriately prescribed medications for depression and anxiety and I felt like they had a poor grasp of the actual disorders as a whole.

PCPs should be more than capable of dealing with depression (up to 3 failed trials of treatment), anxiety, starting initial treatment for psychosis/bipolar and referring on, and basic management of substance use disorders (e.g. managing alcohol withdrawal, suboxone, prescribing MAT)

From what I've seen, I honestly wouldn't trust FMs to start treatment for psychotic or bipolar disorders and I've had to correct my attendings on more than one occasion about statements they made about even the most basic psychiatric disorders (see my regular complaints about "rapid-cycling bipolar disorder"). I've also seen several FMs and Peds people managing ADHD in their patients without even using real criteria or just making statements that are totally unfounded. Personally, I think there's a huge gap between what PCPs should know in the field of psychiatry and what they actually do know, which makes me hesitant with the idea that PCPs should be managing more of the "easier" psych patients.

 

[hamstergang]

so they are allowed to treat children (while IM legally cannot).

I think another poster was trying to tell you this but didn't specifically quote this part of your post: there is no law prohibiting IM from treating kids. Our medical licenses legally allow us to practice any area of medicine and surgery.

With this, to what extent are they trained to deal with Psychiatric patients compared to a Psychiatrist? For example, can a FM physician treat patient A for general medicine, then have pt. B come in for a Psych Diagnostic eval or a pt. visit w/ 30 min of Psychotherapy?

Psychotherapy training takes a long time and requires longitudinal therapy cases with supervision. I doubt any FM residency provides this, though I guess an FM doc could get additional therapy training on their own. FM docs should be able to evaluate and treat some mental illness, but not as severe or complex as a psychiatrist. I imagine the same holds for all fields -- not being a specialist in the field, FM wouldn't be appropriate for the more severe and complexes cases, which is why the specialists exist.

 

[nitemagi]

Psychotherapy training takes a long time and requires longitudinal therapy cases with supervision. I doubt any FM residency provides this, though I guess an FM doc could get additional therapy training on their own. FM docs should be able to evaluate and treat some mental illness, but not as severe or complex as a psychiatrist. I imagine the same holds for all fields -- not being a specialist in the field, FM wouldn't be appropriate for the more severe and complexes cases, which is why the specialists exist.

I have seen a few FM docs who go and get therapy training. They generally describe themselves as "physician, therapist." They're usually undertrained in any serious mental illness, and as you'd expect have about the expertise of a masters level clinician in managing any mental illnesses, which is a narrow range (based on their clinical area of training). Sometimes even less because they're not doing clinical internships with psych-specific illnesses like most psychotherapists -- instead just learning "technique" in training and getting supervision on a handful of patients.

 

[MADD!!!]

My eyes definitely opened up after this thread. When I started it, I was under the impression that Family Medicine Physicians got more training in Psychiatry during residency. Also I always believed that legally Peds couldn't treat patients 18 or older and vice versa for Internal Medicine.

 

[randomdoc1]

But most FM docs have no training and no interest in working with the mentally ill (despite the fact that 70% of mental disorders are treated in primary care) and prescribe everyone xanax.

my opinion is that primary care physicians should be dealing with a different level of mental illness than psychiatrists.

Yea, I see a fair amount of the highly efficacious combo of adderall IR with xanax coming out of primary care. The last one was in a heroin addict...

The holy trinity of medicine ftw! Opiate, benzo, stim . Fixes everything =P.

Another PC case I can think of is putting a very sexually active teenage girl on depakote with no birth control =/.

 

[Stagg737]

I have seen a few FM docs who go and get therapy training. They generally describe themselves as "physician, therapist." They're usually undertrained in any serious mental illness, and as you'd expect have about the expertise of a masters level clinician in managing any mental illnesses, which is a narrow range (based on their clinical area of training). Sometimes even less because they're not doing clinical internships with psych-specific illnesses like most psychotherapists -- instead just learning "technique" in training and getting supervision on a handful of patients.

My current rotation is with a pediatrician who also has a masters in counseling and he pretty much fits your description to a T. He rarely actually does counseling with patients, but you can definitely tell he wants to and tends to spend more time talking to his patients than most medical docs I've worked with.

My eyes definitely opened up after this thread. When I started it, I was under the impression that Family Medicine Physicians got more training in Psychiatry during residency. Also I always believed that legally Peds couldn't treat patients 18 or older and vice versa for Internal Medicine.

The issue isn't with legally treating those patients, it's with reimbursement. So while a psychiatrist can legally do anything an IM doc or surgeon would do, no insurance company to part of gov will reimburse for most of those treatments. To be reimbursed you often have to have completed a residency in that field or a related field (like an FM doc treating kids), and to get premium reimbursement be board-certified.

 

[Armadillos]

I think it’s a little unfair to say FM gets no training treating psychiatric patients. They get massive amount of training treating stuff like depression/anxiety/insomnia in their clinics, they just aren’t being trained by psychiatrists so their skills and interests vary widely.

 

[nitemagi]

I think it’s a little unfair to say FM gets no training treating psychiatric patients. They get massive amount of training treating stuff like depression/anxiety/insomnia in their clinics, they just aren’t being trained by psychiatrists so their skills and interests vary widely.

This is the nature of an apprentice model. Since they're not being taught by those with clear expertise, there's a high risk of the blind leading the blind.

 

[Ceke2002]

Yea, I see a fair amount of the highly efficacious combo of adderall IR with xanax coming out of primary care. The last one was in a heroin addict...

The holy trinity of medicine ftw! Opiate, benzo, stim . Fixes everything =P.

When I was still on the methadone program, the GP that was the prescribing physician had this really strange idea that if he just kept all his patients completely pilled out, then they wouldn't crave heroin as much. So stupidly large doses of benzos for everyone!

Having said that I've seen both good and bad treatment of Psychiatric issues from primary care Doctors.

 

[SeniorWrangler]

People don't always talk about it, but there's really two distinct kind of problems people seek out therapy for, with some overlap:
1) Problems of living (I don't love my spouse any more, my mother in law hates me, my boss hates me, I keep dating people who are unsuitable)
2) Major psychiatric issues (self-injury, suicidality, psychosis, etc)

Most people with Type 1 problems don't end up seeing a psychiatrist or psychologist for their issues. They see an social worker or a religious leader with some counseling experience or a "therapist" with no special degree or a family member. They could see their family doctor, too.

 

[nitemagi]

People don't always talk about it, but there's really two distinct kind of problems people seek out therapy for, with some overlap:
1) Problems of living (I don't love my spouse any more, my mother in law hates me, my boss hates me, I keep dating people who are unsuitable)
2) Major psychiatric issues (self-injury, suicidality, psychosis, etc)

Most people with Type 1 problems don't end up seeing a psychiatrist or psychologist for their issues. They see an social worker or a religious leader with some counseling experience or a "therapist" with no special degree or a family member. They could see their family doctor, too.

From my experience, type 2 problems can many times be due to type 1 problems that just got out of hand (outstripped the coping resources of the individual, didn't resolve adequately with time, became cumulative, etc). Even some cases that would typically have been diagnoses as psychosis have resolved when working with good therapy, appropriately.

 

[smalltownpsych]

People don't always talk about it, but there's really two distinct kind of problems people seek out therapy for, with some overlap:
1) Problems of living (I don't love my spouse any more, my mother in law hates me, my boss hates me, I keep dating people who are unsuitable)
2) Major psychiatric issues (self-injury, suicidality, psychosis, etc)

Most people with Type 1 problems don't end up seeing a psychiatrist or psychologist for their issues. They see an social worker or a religious leader with some counseling experience or a "therapist" with no special degree or a family member. They could see their family doctor, too.

Great point, although I do get to see quite a few in the first category. Also, as you might have implied when talking about the overlap, a lot of those who are in the first category, once treated, end up in the first category too.

 

[RTC19]

Hope it's okay if I chime in. I'm a clinical research coordinator in CAP and like to lurk in this forum sometimes.

I think especially for our child and adolescent population where psych takes forever and a day to get an appointment with (6 months for the local private practices that do NOT take Medicaid, 9-12 months for the big children's hospital that does), family physicians and general pediatricians who are comfy with some basic psychiatric problems can be a godsend. I think just a willingness to make referrals to a therapist/helping parents look into less expensive options for therapy if they can't afford a child psychologist and a willingness to start an SSRI when indicated while the patient waits for their psychiatry appointment can be very helpful in preventing problems from snowballing into the aforementioned suicidality/self-injury.

However, from my experience (and granted, I work at a big ole academic children's hospital) it seems like their role is more as first-contact physicians and serious stuff definitely does (and should) get referred to psychiatry.

Please note my bias that my primary care physician prescribes my Zoloft for my very stable depression and he is wonderful. He sought out additional formal psychiatry training in his Internal Medicine residency because he knew he was interested in primary care after graduation.

 

[TexasPhysician]

I think especially for our child and adolescent population where psych takes forever and a day to get an appointment with (6 months for the local private practices that do NOT take Medicaid, 9-12 months for the big children's hospital that does), family physicians and general pediatricians who are comfy with some basic psychiatric problems can be a godsend.

A large portion of even Medicaid patients can afford a few private CAP appointments before getting in elsewhere. Almost all can afford a 1x consult before FM can handle things until access is obtained at a large academic center. They just rarely prioritize psychiatric care over luxuries. Even at academic centers, the no-show rate of Medicaid is much higher than every other insurance. I can’t tell you how many times a parent has complained about the cost of an evaluation while playing on a phone that is nicer than mine.

 

[Shikima]

FM residency training consists of 2 weeks "behavioral medicine" during the internship.

 

[NRP]

I think it's residency dependent. I've seen several where it's a month of psych training during the 2nd or 3rd years.

 

[MADD!!!]

People don't always talk about it, but there's really two distinct kind of problems people seek out therapy for, with some overlap:
1) Problems of living (I don't love my spouse any more, my mother in law hates me, my boss hates me, I keep dating people who are unsuitable)
2) Major psychiatric issues (self-injury, suicidality, psychosis, etc)

Most people with Type 1 problems don't end up seeing a psychiatrist or psychologist for their issues. They see an social worker or a religious leader with some counseling experience or a "therapist" with no special degree or a family member. They could see their family doctor, too.

Yes! I was referring to #1. This is what I mean -- Can a FM physician see a pt. who has Type 1 problems and actually bill for Psychotherapy as well (like a 30 min session)? And yes of course, if they see anything more severe than refer out to Psych. I would imagine it to be fun as a FM physician to get SOME Psych patients for treatment as well.

 

[smalltownpsych]

Yes! I was referring to #1. This is what I mean -- Can a FM physician see a pt. who has Type 1 problems and actually bill for Psychotherapy as well (like a 30 min session)? And yes of course, if they see anything more severe than refer out to Psych. I would imagine it to be fun as a FM physician to get SOME Psych patients for treatment as well.

Medical doctors bill for talking to patients all the time and there are codes for that, but it takes specialized and supervised training to provide psychotherapy. In the glory days of psychoanalysis there were docs from all fields getting extensive experience training to provide psychoanalytical therapy, but that is also very specialized and would not be something that you would integrate into a practice. These days it wouldn’t make much sense. After all, I know quite a bit of medical stuff too, should I dabble in that with my patients? Unfortunately, most people don’t realize the importance of effective psychoyptherapy and the harm that doing it poorly causes. Just like you would be able to spot my amateur medical mistakes easily so can I see the harm caused by poorly trained osychotherapists. Don’t be one of them.

 

[MADD!!!]

Medical doctors bill for talking to patients all the time and there are codes for that, but it takes specialized and supervised training to provide psychotherapy. In the glory days of psychoanalysis there were docs from all fields getting extensive experience training to provide psychoanalytical therapy, but that is also very specialized and would not be something that you would integrate into a practice. These days it wouldn’t make much sense. After all, I know quite a bit of medical stuff too, should I dabble in that with my patients? Unfortunately, most people don’t realize the importance of effective psychoyptherapy and the harm that doing it poorly causes. Just like you would be able to spot my amateur medical mistakes easily so can I see the harm caused by poorly trained osychotherapists. Don’t be one of them.

You're right, I completely agree. I appreciate the response!

 

[VA Hopeful Dr]

FM residency training consists of 2 weeks "behavioral medicine" during the internship.

Ours was a month split between our FM/Pysch attending in his clinic and the IM/Psych attending who ran the geriatric psych floor at the hospital, in 3rd year.

 

[SeniorWrangler]

Medical doctors bill for talking to patients all the time and there are codes for that, but it takes specialized and supervised training to provide psychotherapy. In the glory days of psychoanalysis there were docs from all fields getting extensive experience training to provide psychoanalytical therapy, but that is also very specialized and would not be something that you would integrate into a practice. These days it wouldn’t make much sense. After all, I know quite a bit of medical stuff too, should I dabble in that with my patients? Unfortunately, most people don’t realize the importance of effective psychoyptherapy and the harm that doing it poorly causes. Just like you would be able to spot my amateur medical mistakes easily so can I see the harm caused by poorly trained osychotherapists. Don’t be one of them.

See my response above. You could call one "counseling" and one "psychotherapy" if you like.

 

[smalltownpsych]

See my response above. You could call one "counseling" and one "psychotherapy" if you like.

The semantics aren't as important as being clear as to the role. An effective family practitioner is (or should?) typically going to have some good counselling skills to connect with patients, express compassion, get patient to open up, and assess basic mental health issues. Also, the main focus of the family doc would be the physical well-being of the patient. It would be kind of weird for them to say come back next week and we'll talk more about your relationship patterns. Almost as weird as if I asked my patients about their bowel movements or they showed me that strange growth on their body.

 

[michaelrack]

. Almost as weird as if I asked my patients about their bowel movements or they showed me that strange growth on their body.

Not weird at all for inpatient psychiatrists, especially those who deal with older patients

 

[Attending1985]

I know we talk a lot about fm docs lacking training but isn’t like 90% of therapeutic effect attributed to the relationship between therapist and patient. Maybe a doc with natural ability would be good at this despite lacking training?

 

[thoffen]

I know we talk a lot about fm docs lacking training but isn’t like 90% of therapeutic effect attributed to the relationship between therapist and patient. Maybe a doc with natural ability would be good at this despite lacking training?

Perhaps but good therapy training is probably more what not to do than what to do. Will that naturally therapeutic doc be able to understand and maintain appropriate therapeutic boundaries? Aside from this, if the doc is expected to recognize and manage major mental illness that's a whole different animal altogether. Given how many psychiatrists do it badly after 4 years of training, I'd be leery of imagining a FM doc will have the same competency.

 

[QueenJames]

My FM preceptor has patients with anxiety and depression and he manages their meds for them.

If they wanna see a shrink, they can get a referral.

 

[Ceke2002]

Hey Everyone,

So I understand that FM physicians get training in Psychiatry as part of their residency. With this, to what extent are they trained to deal with Psychiatric patients compared to a Psychiatrist? For example, can a FM physician treat patient A for general medicine, then have pt. B come in for a Psych Diagnostic eval or a pt. visit w/ 30 min of Psychotherapy?

In Australia most GPs in practice today at least have enough training to be able to effectively manage things like mild to moderate depression, or simple anxiety - with or without a referral to a psychologist for therapy as needed. Sometimes a patient will be referred for a Psychiatric assessment first, and then a treatment plan is drawn up which is primarily the GPs responsibility to manage (with say quarterly reviews by the Psychiatrist, or as needed). I personally find the problems begin when GPs overstep the bounds of their knowledge/training, and start thinking that they can replace psychiatric or psychological care completely.

 

[Ceke2002]

I know we talk a lot about fm docs lacking training but isn’t like 90% of therapeutic effect attributed to the relationship between therapist and patient. Maybe a doc with natural ability would be good at this despite lacking training?

Well, yeah, but the other 10% of the equation they better be able to actually do the therapy component. I've been to therapists who were naturally very empathetic, and kind, and attuned, and easy to talk to - and I didn't last more than 3 sessions with either of them seeing as it very quickly became obvious that their actual therapy skills were sorely lacking. There is a lot more to effective therapy than just simply developing a good rapport, or having a 'good beside manner' with a patient.

 

[Stagg737]

In underserved areas, non MH physicians have to learn how to manage psychiatric meds. I know an rural EM doc who feels comfortable starting and managing antipsychotics and SSRIs. A FM doc friend recently curbsided me on how to manage thioridazine in a geriatric patient with EPS. There are just no available psychiatrists where they work.

Just want to point out that feeling comfortable and being properly trained/qualified to manage a condition and administer treatment are two very different things. I've rotated with physicians who were comfortable treating psych patients but regularly said and did things that were pretty obviously incorrect to anyone with even basic foundational knowledge in the field. I think it would be great if PCPs would handle simple cases more often, but some are so poorly trained that I wouldn't even trust them with that (and I haven't even started residency yet!).

 

[Attending1985]

Just want to point out that feeling comfortable and being properly trained/qualified to manage a condition and administer treatment are two very different things. I've rotated with physicians who were comfortable treating psych patients but regularly said and did things that were pretty obviously incorrect to anyone with even basic foundational knowledge in the field. I think it would be great if PCPs would handle simple cases more often, but some are so poorly trained that I wouldn't even trust them with that (and I haven't even started residency yet!).

Can you give an example?

 

[NickNaylor]

Relatively uncomplicated cases of depression and anxiety are well within the wheelhouse of a generalist (IM, FM, etc.) and do not necessarily require referral to a psychiatrist. Anything beyond that, however, and I think you start to get into dicey territory as a non-psychiatrist. Diagnosis can be subtle and psychopharmacology is complex. As mentioned previously, there are plenty of psychiatrists who do it poorly after 4 years of specialized training - I'm not sure how we can reasonably expect an IM/FM doc to be reasonably versed in even minimally complicated cases.

With respect to the question of psychotherapy, psychotherapy is more than just having a chat, although that can be therapeutically valuable. Direct, person-to-person contact serves a purpose, absolutely. But to imagine someone without specific psychotherapeutic training - much less the basis of psychiatric diagnosis upon which a recommendation for and approach to psychotherapeutic treatment would be based on - providing psychotherapy is somewhat laughable. Add to that the reality of how PCP-based care is provided in mainstream medical systems - ignoring some seriously concierge models - and I can't imagine that a PCP would actually want to provide psychotherapy services, much less be competent to do so.

 

[Stagg737]

Can you give an example?

The strangest one that's easiest for me to remember was my FM attending. She was overall a solid physician, but she had a lot of weird beliefs in the area of psych. For example, when a patient would come in with depression and anxiety, she'd ask them where their symptoms fell on a scale, with 1 being mostly depression and 10 being mostly anxiety. She said that if their symptoms fell mostly on the depression side, she'd start them on zoloft because it works great just for depression. If their symptoms were mostly on the anxiety side, then she'd prescribe paxil because it always works the best for anxiety. If it was right in the middle she'd recommend prozac. I asked her how she felt about other SSRIs like lexapro or duloxetine and she said she just didn't typically use them unless patients asked. This was after I'd had 2 psych rotations, and I'd never heard of anything like that or since then.

I've heard IM docs state that they don't believe in benzos because everyone who uses them becomes an addict and docs say that no child should take a stimulant for ADHD because it will certainly stunt their growth. I've also heard non-psychiatrists state that they don't believe in ADHD at all and think that every overly hyperactive child is a product of bad parenting. I also can't begin to count the number of times I've seen a teen or young adult who clearly has borderline personality issues come in and their PCP tells the parents/them that their daily mood swings are due to "rapid cycling bipolar". I legitimately don't think I've ever met a PCP who actually knows the diagnostic criteria for RCBP, and I certainly haven't met any who recommended the appropriate treatment for those they're labeling with such.

 

[Celexa]

Can you give an example?

I'm not who you asked, but I rotated through a large family med practice where it seemed like the first choice psych med was ALWAYS wellbutrin. I can't count the number of people who came in for mild-moderate depression or anxiety and were started on wellbutrin. It was much rarer for an ssri to be used first. Some, but not all, of those docs also thought wellbutrin WAS an SSRI.

These were otherwise good docs and I didn't have concerns about the medical care of their patients. I have a ton of respect for family docs but it did seem like ignorance on basic psych issues was more prevalent and culturally accepted than ignorance of other fields.

 

[VA Hopeful Dr]

I'm not who you asked, but I rotated through a large family med practice where it seemed like the first choice psych med was ALWAYS wellbutrin. I can't count the number of people who came in for mild-moderate depression or anxiety and were started on wellbutrin. It was much rarer for an ssri to be used first. Some, but not all, of those docs also thought wellbutrin WAS an SSRI.

These were otherwise good docs and I didn't have concerns about the medical care of their patients. I have a ton of respect for family docs but it did seem like ignorance on basic psych issues was more prevalent and culturally accepted than ignorance of other fields.

Or maybe we have lots of patients with anorgasmia from SSRIs and Wellbutrin is pretty good for depression, and occasionally anxiety (though much more hit or miss there).

 

[Attending1985]

The strangest one that's easiest for me to remember was my FM attending. She was overall a solid physician, but she had a lot of weird beliefs in the area of psych. For example, when a patient would come in with depression and anxiety, she'd ask them where their symptoms fell on a scale, with 1 being mostly depression and 10 being mostly anxiety. She said that if their symptoms fell mostly on the depression side, she'd start them on zoloft because it works great just for depression. If their symptoms were mostly on the anxiety side, then she'd prescribe paxil because it always works the best for anxiety. If it was right in the middle she'd recommend prozac. I asked her how she felt about other SSRIs like lexapro or duloxetine and she said she just didn't typically use them unless patients asked. This was after I'd had 2 psych rotations, and I'd never heard of anything like that or since then.

I've heard IM docs state that they don't believe in benzos because everyone who uses them becomes an addict and docs say that no child should take a stimulant for ADHD because it will certainly stunt their growth. I've also heard non-psychiatrists state that they don't believe in ADHD at all and think that every overly hyperactive child is a product of bad parenting. I also can't begin to count the number of times I've seen a teen or young adult who clearly has borderline personality issues come in and their PCP tells the parents/them that their daily mood swings are due to "rapid cycling bipolar". I legitimately don't think I've ever met a PCP who actually knows the diagnostic criteria for RCBP, and I certainly haven't met any who recommended the appropriate treatment for those they're labeling with such.

Wow I have had the completely opposite experience with benzos and PCPs. Wish they were like that around here:

 

[Celexa]

Or maybe we have lots of patients with anorgasmia from SSRIs and Wellbutrin is pretty good for depression, and occasionally anxiety (though much more hit or miss there).

I was genuinely curious about what was a clear practice habit and I asked every doc I saw prescribe Wellbutrin as an initial med why they did it (in the appropriate deferential med student voice). I would have understood it a lot more if the above were the justifications given, but when I asked I got responses along the lines of a)"wellbutrin is an ssri" b)"maybe it'll help them stop smoking" (but in patients who were not told about wellbutrin's effects in that area, and had not stated any desire to stop smoking at that time). I also didn't see any attempt to differentiate primarily depressive symptoms from high anxiety patients. That seemed to partly be due to the fact so many thought it was an SSRI--ie, the docs seemed to view it as an SSRI that didn't cause anorgasmia rather than being in a separate class and therefore maybe not being the best choice for initial treatment of anxiety.

My main impression from that rotation ended up being that while the family docs at that practice worked hard to stay up on the latest practices for medical issues (for example, I saw no difference between the basic ob/gyn care there vs. an ob/gyn clinic, aside from the ob/gyn clinic understandably having a higher proportion of more complicated cases), their psych knowledge seemed sparse and calcified. I know it's not the same everywhere, but the question was asked and this was my experience.

 

[Stagg737]

I'm not who you asked, but I rotated through a large family med practice where it seemed like the first choice psych med was ALWAYS wellbutrin. I can't count the number of people who came in for mild-moderate depression or anxiety and were started on wellbutrin. It was much rarer for an ssri to be used first. Some, but not all, of those docs also thought wellbutrin WAS an SSRI.

I've encountered similar issues as well. Did an outpatient peds rotation where the guy was near retirement and basically only did child psych issues and well-checks and was considering switching over to being a counselor in retirement and managing basic psych meds. He didn't know what lexapro was, thought atomoxetine was exclusively an SSRI, and was yet another PCP telling parents their 14 year old daughters with daily mood swings were developing rapid cycling bipolar.

Wow I have had the completely opposite experience with benzos and PCPs. Wish they were like that around here:

I've also seen the opposite where benzos are passed out like candy. The only time I've seen a PCP properly prescribe benzos was when they were just continuing a psychiatrist's treatment plan. I feel like there are such differing views on benzos that it's often hard for those not formally trained in when it's appropriate to use them to actually know what's reasonable.

My main impression from that rotation ended up being that while the family docs at that practice worked hard to stay up on the latest practices for medical issues (for example, I saw no difference between the basic ob/gyn care there vs. an ob/gyn clinic, aside from the ob/gyn clinic understandably having a higher proportion of more complicated cases), their psych knowledge seemed sparse and calcified. I know it's not the same everywhere, but the question was asked and this was my experience.

The bolded has also been my experience. Very few PCPs I've encountered seem to have kept up on their psychiatric knowledge beyond the most basic principles. Sometimes not even that, which is really a shame since there's such a drastic need for better psychiatric care and the most basic cases shouldn't be that hard to treat.

 

[VA Hopeful Dr]

I was genuinely curious about what was a clear practice habit and I asked every doc I saw prescribe Wellbutrin as an initial med why they did it (in the appropriate deferential med student voice). I would have understood it a lot more if the above were the justifications given, but when I asked I got responses along the lines of a)"wellbutrin is an ssri" b)"maybe it'll help them stop smoking" (but in patients who were not told about wellbutrin's effects in that area, and had not stated any desire to stop smoking at that time). I also didn't see any attempt to differentiate primarily depressive symptoms from high anxiety patients. That seemed to partly be due to the fact so many thought it was an SSRI--ie, the docs seemed to view it as an SSRI that didn't cause anorgasmia rather than being in a separate class and therefore maybe not being the best choice for initial treatment of anxiety.

My main impression from that rotation ended up being that while the family docs at that practice worked hard to stay up on the latest practices for medical issues (for example, I saw no difference between the basic ob/gyn care there vs. an ob/gyn clinic, aside from the ob/gyn clinic understandably having a higher proportion of more complicated cases), their psych knowledge seemed sparse and calcified. I know it's not the same everywhere, but the question was asked and this was my experience.

That's fair, I was just giving a common reason (and mine as well) for why I'd use Wellbutrin more if I could.

 

[Candidate2017]

Ours was a month split between our FM/Pysch attending in his clinic and the IM/Psych attending who ran the geriatric psych floor at the hospital, in 3rd year.

I saw more patients and did more work on my med school psych rotations than our FM residents rotating through psychiatry. They show up here and there and mumble something about clinic, didactics or other obligation and then I never see them again.

 

[VA Hopeful Dr]

I saw more patients and did more work on my med school psych rotations than our FM residents rotating through psychiatry. They show up here and there and mumble something about clinic, didactics or other obligation and then I never see them again.

As always, program dependant

 

[door_to_balloon_knot]

I saw more patients and did more work on my med school psych rotations than our FM residents rotating through psychiatry. They show up here and there and mumble something about clinic, didactics or other obligation and then I never see them again.

And God bless you for allowing this tradition to continue

o7

 

[hallowmann]

Yeah, this is unfortunately one of those that varies wildly from program to program. Some residencies have you actually working on a psych unit or on the CL service, others have you doing "behavioral health" with an LISW for 2-4 weeks, others have you in a psychiatry outpatient clinic, and I even saw a few places that have you doing 4 months of behavioral health that mixes those settings alongside continuity clinics with tons of primary psychiatric conditions.

PCPs should be able to manage mild to moderate anxiety and depression, obviously should be able to refer to psychotherapy, and in the resource low areas should probably be able to initiate treatment in more complex disorders or maybe work in a collaborative vs integrative care model with a psychiatrist as they await formal evaluation.

Do they all do a great job, no. Do all psychiatrists, no. Do all PNPs, no.

 

[sloop]

My impression is that basic anxiety and depression management is within the scope of a primary care/FM doctor. If they are interested in it, they could also do suboxone.

In an ideal world, they would be able to do multiple trials of antidepressants before referring, but I don’t think this is always a realistic expectation. There is no theoretic reason they would not be capable of this, but I have found that many PCPs are not great at identifying what actually constitutes treatment failure in the first place. They often don’t have a good understanding of what doses would be required to expect a response in patients or what the maximum dose of a given medication actually is (which is not always the FDA maximum recommended dose). I have seen too many patients who were tried on like 5 antidepressants, but these trials included like 50 mg of Zoloft, 40 mg of Prozac and 10 mg of Lexapro.

I think that bipolar disorder and psychosis are largely outside of the scope of a PCP. This is mostly because treatment for these disorders is often much more complicated than for depression and the medications have a greater incidence of severe side-effects. There are a few medications that, as a general rule, I don’t think PCPs should touch in the absence of guidance by a psychiatrist. Clozapine and MAOIs are definitely in this category. Tricyclics and lithium arguably are as well.

A lot of this also changes if they have had more psychiatric training than the typical FM doc or PCP. Some primary care docs in programs focused on things like urban mental health or the like do actually rotate through psychiatry as residents. These physicians can probably do more, but I’d still say that treatment refractory and complicated cases require a referral.