Feeling discouraged as a psychiatrist, switch field?

[nancysinatra]

Yeah patients temp is around 95 and has a defribillator.

Lewy body is also on top of our differential.

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It's nice to hear a discussion on the Psych forum where the word "differential" is used and then following it, are actual words pertaining to actual medically known diseases that could be causing the patient's symptoms and also importantly their lab values, and which conditions can then be systematically ruled out using a methodology that involves testing (literally, with labs or imaging) a hypothesis rather than merely some person deliberating over a checklist of totally vague complaints. ("Differential" in psychiatry is usually code for: "Now I'm going to list 5 overlapping and equally amorphous conditions from the DSM which may or may not actually exist and which there is no way to distinguish from one another."

I'm not sure exactly how you get from a TSH of 30 to myxedema coma, and it's not exactly the most interesting medical find of all time, but good luck with figuring out what's going on!

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[Ellaellafan]

Hey there - I think it's interesting how a lot of people responding to your post are honing in on the "respect" thing. I get that, and agree that you should look beyond that. But if it persists, then maybe there’s more to it. It doesn’t mean you’re a bad person just because you “care” how you are perceived within the larger world of medicine. Maybe it just means you want to be a decent doctor. Conscientious health care providers ought to care how their specialty is regarded by the rest of the medical profession, right?

It is possible to choose the wrong specialty. Only you can know. But I don't agree with the idea that you should only change fields if there is one other exact thing you want to do. You should switch if you want to switch, and that’s about all. It's your life, and you need to use your own priorities in deciding.

You mentioned that psychiatry was the last field you ever thought you would choose when you started med school. I am in the same boat. (And I am changing fields.) I wasn’t interested in psych when I started med school. My interests were anesthesia, EM, surgery, or certain IM subspecialties. And I wanted to do something international.

So it makes no sense that I went into psychiatry! But the reason I did was sort of like what you’re saying about C/L. In my case I liked the psychoanalytic concepts I was introduced to in my med school psych clerkship. (I hadn’t yet learned that it takes 7 extra years or so to become an analyst and that analysis is not at all in demand.) I liked learning about eating disorders and personality disorders OTHER than borderline (because I’m not interested in suicide, and suicide attempts are the defining feature of BPD). I actually thought I could contribute to society by helping to cure some of these irrational conditions, many of which cause great havoc to humanity! (Such as NPD, or paranoid PD…). The key word is “cure.” Well, it took me four years of residency to learn that no one besides me is actually hoping to “cure” these conditions. PDs are poorly understood, and their prognosis remains horrible. In a way they are like neglected tropical diseases, like leishmaniasis. I wish someone had told me this 8 years ago!!!

The other thing that interested me was the rarer conditions, like dissociative fugue and political brainwashing. I’ve been doing psychiatry for over 7 years now, and I’ve never seen a case. Instead, I spend my days doing “suicide risk assessments,” because that is where the field is going.

But I didn’t quit right away, and I'm mostly glad. I have worked for a few years now, and learned a lot about about what I want. I’ve made a dent in my loans. I think I’ve helped people even if I don’t go home at the end of the day marveling at the latest depressed person whose life I changed by switching them from Effexor to Cymbalta.

Maybe you'll work for a couple years and decide you love C/L. Or maybe not. It might help to take a bit of time in an unpressured work setting to try to figure that out. Eventually you will figure out what you need to do. Good luck!

Thanks. Which field are you going into and how are you going about it?

 

[Ellaellafan]

Sure, but my point was Psychiatry has a variety of interests, not just a sole field. Maybe not pathophysiology, but whats the psychopharmacology of depression ? Or the neuroanatomy of cocaine addiction?

I realize Breast/IR have patient contact, but I meant for most DR guys. Especially since next year DR and IR are going to be separate matches.

I just finished my on call, and we had an interesting patient, in 70s with visual hallucinations for a few months. Medical team obviously consults us, we ordered labs, including TSH (patient seemed to have some cognitive impariment, constipation, etc.) . Turns out TSH is 30! Myxedema Crisis. My attending and I did some reading and it looks like patient has hypothyroid induced psychosis!

Pretty cool, and the reason why I love psych

Those are the momemts that make me think maybe I made the right choice lol. That's why I'm confused.

 

[zolof]

I did CL fellowship. And then only CL and inpatient since mostly and in 5 or 6 different hospitals. LET me tell you. There is no way in hell they could survive without us. Try abandoning them for hours, days or weeks. They will be begging.. The ER cannot live without us. They used to hug me and offer me anything I wanted when I would do consults. Had nothing but respect. There were of course a very few certain MDs in different specialties that were narcassitic assholees who were that way to all people. If anyone acted that way to me. I would throw it back in their face, I don't take that crap from anyone. Now I can't tell you how many times, internal medicine and ob/gyn, ED docs came up to me and secretly said, "I wish I did psychiatry". The clinical labor of patient care, no matter what speciality, will tire, overwhelm and exhaust you and drain you to the core. Its the nature of taking care of very sick and needy and scared patients and their families. Thats just the nature of it and the reality of medicine in general.

 

[Ellaellafan]

I get mistaken for a physician all the time, in part because I am one psychologist in a department of medical subspecialists. Talk about respect.

You can apologize for your existence, or you can name the problem with clear eyes and do your work regardless of your non-psychiatrist colleagues' knowledge deficits and unprofessional behavior.

I remember the first time I p*ssed off a referring physician because I refused a consult after she was unable to articulate a coherent referral question or even a clear goal for my seeing the patient. All I knew was that I was being called in at the sad tail end of a long journey with a challenging patient, and I wasn't about to shoot myself in the foot when the team was already preparing to transfer the patient to another facility. That incident informed my rallying cry: if you want me on your team, I'm yours. If you want a dumping ground, find someone else.

Find an environment where you are a respected member of the team most of the time, and the stupid calls will roll off your back more easily. You are so much more than an "add-on."

Thanks!

 

[nancysinatra]

The clinical labor of patient care, no matter what speciality, will tire, overwhelm and exhaust you and drain you to the core. Its the nature of taking care of very sick and needy and scared patients and their families. Thats just the nature of it and the reality of medicine in general.

And then there's sports medicine...

 

[Ellaellafan]

I did CL fellowship. And then only CL and inpatient since mostly and in 5 or 6 different hospitals. LET me tell you. There is no way in hell they could survive without us. Try abandoning them for hours, days or weeks. They will be begging.. The ER cannot live without us. They used to hug me and offer me anything I wanted when I would do consults. Had nothing but respect. There were of course a very few certain MDs in different specialties that were narcassitic assholees who were that way to all people. If anyone acted that way to me. I would throw it back in their face, I don't take that crap from anyone. Now I can't tell you how many times, internal medicine and ob/gyn, ED docs came up to me and secretly said, "I wish I did psychiatry". The clinical labor of patient care, no matter what speciality, will tire, overwhelm and exhaust you and drain you to the core. Its the nature of taking care of very sick and needy and scared patients and their families. Thats just the nature of it and the reality of medicine in general.

Yeah. Used to bother me when I'm interviewing a pt and another speciality walks in and tries to sneak in their pt visit. Now I ask them to wait. I guess if I don't show I deserve respect, they won't give it.

 

[nancysinatra]

Yes, it's narcissistically injuring to not be respected as some services, but you have to make peace with the fact that the world we live in privileges technical solutions to problems and that's not how we roll.

I take issue with your use of the term "narcissistically injuring" here, and also with the idea that we are some antediluvian specialty by choice, as in, "that's how we roll, being all non-technological and all..."

It's not a narcissistic injury for those of us in psychiatry to be faced with the reality that we are behind other specialties. It's an actual injury. We are behind. We don't merely lack technical solutions - we lack solutions, period. I read in the New York Times yesterday that the suicide rate in the US is at the highest in 30 years. If we have one job, it is to reduce the rate of suicide. Not only has the suicide rate risen, but there is speculation that the cause is largely economic (and would seem to have nothing to do with psychiatry). But economics is not even mentioned in the DSM. Nor is anything else outside of the "checklist of symptoms." Huh? So I spent four years learning to identify the SIGECAPS symptoms, and it turns out, it's the economy that does people in? After reading that article, I wonder what I spent four years in residency for. Can someone tell me?

I bet, if I'd gotten a PhD in economics and gone to work for a bank, my impact on the US suicide rate would be higher than it is with me being a full time psychiatrist doing nothing day in and day out but doing suicide risk assessments.

 

[Ellaellafan]

I did CL fellowship. And then only CL and inpatient since mostly and in 5 or 6 different hospitals. LET me tell you. There is no way in hell they could survive without us. Try abandoning them for hours, days or weeks. They will be begging.. The ER cannot live without us. They used to hug me and offer me anything I wanted when I would do consults. Had nothing but respect. There were of course a very few certain MDs in different specialties that were narcassitic assholees who were that way to all people. If anyone acted that way to me. I would throw it back in their face, I don't take that crap from anyone. Now I can't tell you how many times, internal medicine and ob/gyn, ED docs came up to me and secretly said, "I wish I did psychiatry". The clinical labor of patient care, no matter what speciality, will tire, overwhelm and exhaust you and drain you to the core. Its the nature of taking care of very sick and needy and scared patients and their families. Thats just the nature of it and the reality of medicine in general.

And yeah I could imagine the face of the other specialities if we disappeared. The amount of work they'd have to do to take care of our patients. ☺

 

[nancysinatra]

And yeah I could imagine the face of the other specialities if we disappeared. The amount of work they'd have to do to take care of our patients. ☺

They'd have to start dealing with psychopathology on their own. Which might be good for them, and good for the patients, too, to have their care more integrated, and their "psych" symptoms stigmatized less.

 

[nitemagi]

I take issue with your use of the term "narcissistically injuring" here, and also with the idea that we are some antediluvian specialty by choice, as in, "that's how we roll, being all non-technological and all..."

It's not a narcissistic injury for those of us in psychiatry to be faced with the reality that we are behind other specialties. It's an actual injury. We are behind. We don't merely lack technical solutions - we lack solutions, period. I read in the New York Times yesterday that the suicide rate in the US is at the highest in 30 years. If we have one job, it is to reduce the rate of suicide. Not only has the suicide rate risen, but there is speculation that the cause is largely economic (and would seem to have nothing to do with psychiatry). But economics is not even mentioned in the DSM. Nor is anything else outside of the "checklist of symptoms." Huh? So I spent four years learning to identify the SIGECAPS symptoms, and it turns out, it's the economy that does people in? After reading that article, I wonder what I spent four years in residency for. Can someone tell me?

I bet, if I'd gotten a PhD in economics and gone to work for a bank, my impact on the US suicide rate would be higher than it is with me being a full time psychiatrist doing nothing day in and day out but doing suicide risk assessments.

I find your lack of faith disturbing.

 

[Blitz2006]

Yeah. Used to bother me when I'm interviewing a pt and another speciality walks in and tries to sneak in their pt visit. Now I ask them to wait. I guess if I don't show I deserve respect, they won't give it.

Yeah I'm not sure its just psychiatrists that get a lack of respect.

I remember when I was a intern on my medicine rotation, anytime a patient had to go for surgery, they always needed "cardiac clearance". And obviously, we would never call cardiology until like the morning of the operation, and this would piss off the attending cardiologists all the time. I'm sure cardiologists feel "disrespected" in that we expect them to come at 11am, when we call them at 9am, because patient is going under the knife at 12pm.

So its not like we're the only specialty that gets "disrespected".

I honestly think respect is individually based. If you're a confident, good psychiatrist that gives good recs on your consults, you will get respect. There are surgeons that have bad reputations in our hospital and therefore get no respect.

Moral of story: Whatever you do, be good at it.

 

[nancysinatra]

I find your lack of faith disturbing.

Faith??? I find it disturbing that you are likening a medical specialty to religious belief. But thanks for at least acknowledging that that's what we're talking about. I've been worried for quite awhile that psychiatry was plagued by pseudoscience, but it never occurred to me until now that, in fact, it's just a religion.

 

[nitemagi]

Faith??? I find it disturbing that you are likening a medical specialty to religious belief. But thanks for at least acknowledging that that's what we're talking about. I've been worried for quite awhile that psychiatry was plagued by pseudoscience, but it never occurred to me until now that, in fact, it's just a religion.

So serious so serious. It's a line from Star Wars, buddy.

 

[nancysinatra]

Yeah I'm not sure its just psychiatrists that get a lack of respect.

I remember when I was a intern on my medicine rotation, anytime a patient had to go for surgery, they always needed "cardiac clearance". And obviously, we would never call cardiology until like the morning of the operation, and this would piss off the attending cardiologists all the time. I'm sure cardiologists feel "disrespected" in that we expect them to come at 11am, when we call them at 9am, because patient is going under the knife at 12pm.

So its not like we're the only specialty that gets "disrespected".

I honestly think respect is individually based. If you're a confident, good psychiatrist that gives good recs on your consults, you will get respect. There are surgeons that have bad reputations in our hospital and therefore get no respect.

Moral of story: Whatever you do, be good at it.

This is all true, but those surgeons rely upon and need the cardiology asssessments before they can operate. There's a reason it's called cardiac CLEARANCE. So even if they're being rude, it's not the same as if they were dismissing the entire field of cardiology, or stigmatizing heart conditions and the people who treat them.

It pains me that I need to state something so obvious, but people can live, and even survive surgery, with debilitating psychiatric conditions, but NOT with unaddressed lethal heart problems. Plus, under anesthesia, all psych conditions go away, at least temporarily. Again, not so with heart problems. So I really find it hard to believe that even the rudest surgeons truly look down upon cardiology. At some level, they must respect cardiologists.

Whereas surgeons can operate with or without psychiatry's input. When they consult us, often I think they just want us to come by, wave our magic wands, and make difficult patients be quiet. I hate to say it, but think a lot of other specialties look at psychiatry that way. No one EVER asks us for our medical input. If we find something medical by happenstance, during a delirium workup, for example, it's helpful, but not what they were expecting from us.

I experienced the feeling of being dismissed by other specialities on C/L myself. It isn't imaginary. If people around here want to rationalize it by saying "all medical specialties disregard each other to some extent" - go ahead, but the stigma is still real.

 

[Wilf]

The other thing that interested me was the rarer conditions, like dissociative fugue and political brainwashing. I’ve been doing psychiatry for over 7 years now, and I’ve never seen a case. Instead, I spend my days doing “suicide risk assessments,” because that is where the field is going.

True and quite sad. I've noticed that the dumber the attending, the more importance they place on the suicide risk assessment.

 

[nancysinatra]

So serious so serious. It's a line from Star Wars, buddy.

Oh I did not know that! I'm not a sci-fi person. You should have said ;-)

 

[nancysinatra]

True and quite sad. I've noticed that the dumber the attending, the more importance they place on the suicide risk assessment.

Thank you for saying this!

 

[Blitz2006]

This is all true, but those surgeons rely upon and need the cardiology asssessments before they can operate. There's a reason it's called cardiac CLEARANCE. So even if they're being rude, it's not the same as if they were dismissing the entire field of cardiology, or stigmatizing heart conditions and the people who treat them.

It pains me that I need to state something so obvious, but people can live, and even survive surgery, with debilitating psychiatric conditions, but NOT with unaddressed lethal heart problems. Plus, under anesthesia, all psych conditions go away, at least temporarily. Again, not so with heart problems. So I really find it hard to believe that even the rudest surgeons truly look down upon cardiology. At some level, they must respect cardiologists.

Whereas surgeons can operate with or without psychiatry's input. When they consult us, often I think they just want us to come by, wave our magic wands, and make difficult patients be quiet. I hate to say it, but think a lot of other specialties look at psychiatry that way. No one EVER asks us for our medical input. If we find something medical by happenstance, during a delirium workup, for example, it's helpful, but not what they were expecting from us.

I experienced the feeling of being dismissed by other specialities on C/L myself. It isn't imaginary. If people around here want to rationalize it by saying "all medical specialties disregard each other to some extent" - go ahead, but the stigma is still real.

I respectfully disagree.

Last week I had a consult. Depressed lady with cancer, waiting to go to a hospital for chemo trial. On Zoloft, has QT prolongation. Hemeonc obviously calls us, so we are consulted. Switched patient to wellbutrin. Cardiology was also consulted, and I spoke with the cardiology attending, and he thanked me and said without our input and switch of meds, she wouldn't be cardiac cleared to go to the trial. After the switch her QTc dropped from 480 to 430ms (they wanted below 450ms).

Had another case, patient had muscle spasms, neurologist started patient on baclofen. Patient had AMS, LOC for a few hours. We were consulted. We decided that it was the baclofen that caused this, so we stopped it. 2 days later patient improved, Neurologist thanked us.

Even for surgeries, we are consulted all the time for capacity. Surgeons thank our team, mainly for medical legal reasons, but I never feel disrespected.

Of course no one is going to speak to us about medical issues. We are psychiatrists. I went into psychiatry for my love of neuroscience and psychopharmacology. I sure hope no one asks me for medical input. Thats why I went into psych, to avoid checking monotonous labs and using my stethoscope! I don't want to check INR and K+ everyday. I don't care about that stuff. I dont care if your crackles are fine or coarse. I heard two medical residents arguing if a patient had coarsw or fine crackles. I just shook my dead, smiled and said "so glad I'm in psych". I would much rather research QTc prolongation and psychotropic drugs than argue about that stuff!

My point is, if you are in psych and missing medicine, you can get a taste of it on CL. I personally can't wait to do outpatient/neuromodulatation, but am enjoying my CL rotation. I think you also need a thick skin on consult service. Maybe if you feel disrespected or inferior, its time to switch out? Go into addiction or something else. Splik just posted an awesome thread on fellowships, its quite obvious there is a lot of potential to branch out in psych with the list splik provided.

I agree, we aren't the first line of action at a code, but our job description is different. Psychiatry is primarily a long-term, chronic field. You're not gonna treat schizophrenia, bipolar and depression over night.

I suspect this is the reason over 70% of psychiatrists (if I'm not mistaken) go into outpatient psychiatry.



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[nancysinatra]

I respectfully disagree.

Last week I had a consult. Depressed lady with cancer, waiting to go to a hospital for chemo trial. On Zoloft, has QT prolongation. Hemeonc obviously calls us, so we are consulted. Switched patient to wellbutrin. Cardiology was also consulted, and I spoke with the cardiology attending, and he thanked me and said without our input and switch of meds, she wouldn't be cardiac cleared to go to the trial. After the switch her QTc dropped from 480 to 430ms (they wanted below 450ms).

Had another case, patient had muscle spasms, neurologist started patient on baclofen. Patient had AMS, LOC for a few hours. We were consulted. We decided that it was the baclofen that caused this, so we stopped it. 2 days later patient improved, Neurologist thanked us.

Even for surgeries, we are consulted all the time for capacity. Surgeons thank our team, mainly for medical legal reasons, but I never feel disrespected.

Of course no one is going to speak to us about medical issues. We are psychiatrists. I went into psychiatry for my love of neuroscience and psychopharmacology. I sure hope no one asks me for medical input. Thats why I went into psych, to avoid checking monotonous labs and using my stethoscope! I don't want to check INR and K+ everyday. I don't care about that stuff. I dont care if your crackles are fine or coarse. I heard two medical residents arguing if a patient had coarsw or fine crackles. I just shook my dead, smiled and said "so glad I'm in psych". I would much rather research QTc prolongation and psychotropic drugs than argue about that stuff!

My point is, if you are in psych and missing medicine, you can get a taste of it on CL. I personally can't wait to do outpatient/neuromodulatation, but am enjoying my CL rotation. I think you also need a thick skin on consult service. Maybe if you feel disrespected or inferior, its time to switch out? Go into addiction or something else. Splik just posted an awesome thread on fellowships, its quite obvious there is a lot of potential to branch out in psych with the list splik provided.

I agree, we aren't the first line of action at a code, but our job description is different. Psychiatry is primarily a long-term, chronic field. You're not gonna treat schizophrenia, bipolar and depression over night.

I suspect this is the reason over 70% of psychiatrists (if I'm not mistaken) go into outpatient psychiatry.



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I agree with you about some things - but I'm curious - why did Hem/Onc and cardiology get you involved about a QTc of 480? In my experience, well, first, if a medicine subspecialty is concerned about the cardiac implications of a psych med - they will just stop it, pronto, and inform psych later, if at all, in which case it's no longer a "consultation." And second, a QTc in the 400s is not that extreme. However maybe in this case it has something to do with the patient needing chemo? Can you say more about what prompted this multidisciplinary consult, and how it resulted in this rather conservative approach to the QTc?

I ask because when I was a 4th year psych resident, I finagled my way into a cardiology rotation. I specifically asked the cardiology attending "What do you think about these prolonged QTc's caused by psych meds - in the range of the high 400s - should we really be worried?" He said that is ridiculous - that cardiologists don't get worried about QTc until it's well into the high 500s. The literature on torsades de pointes (and V-tach more generally) is quite meager and does not justify getting worried before that, he said. Plus, a gazillion meds cause prolonged QTc, including many antibiotics. So it's not practical to just change them all.

After that rotation, I then went and made good on my off service experience by doing a little song and dance presentation to the psychiatry department about how we all should chill out about QTcs. But now you're saying that a 480 is super-worrisome? Can you say more please?

As far as capacity - sure,we do those evals, but the surgeons should be doing them. Preferably, psychiatry should never be consulted for capacity, since capacity evals can be done by any MD, ideally one who actually knows the risks, benefits, and alternatives to the treatment being proposed.

As far as course vs fine crackles, can you say more about why you consider lung sounds to be uninteresting, and yet are interested in psychiatry, where we have to ask patients on a daily basis whether their sleep disturbance is of the "delayed onset" vs the "frequent awakening" type? Sleep complaints are a mainstay of psychiatry, possibly its biggest mainstay. In order to appreciate sleep complaints, I have to use my ears, in order to hear the patient tell me what is wrong with their sleep. And generally they use one of a handful of descriptors, which include "bad," "ok" "restless," "not good," etc. I don't see how that is any different from trying to appreciate lung sounds, other than with lung sounds, I'd have to pay for a stethoscope in order to hear what's going on with the patient, and so I suppose you could argue that being a psychiatrist is about $200 less expensive than being an internist or pulmonologist. But either type of complaint, if you hear them 20 times a day for 40 years, is going to get boring. So can you say what it is that makes you not care about lung crackles but do care about psych complaints?

Also, if you find labs monotonous and don't like using a stethoscope, can I ask why you went to medical school?

 

[deleted343839]

If we have one job, it is to reduce the rate of suicide. Not only has the suicide rate risen, but there is speculation that the cause is largely economic (and would seem to have nothing to do with psychiatry). But economics is not even mentioned in the DSM. Nor is anything else outside of the "checklist of symptoms." Huh? So I spent four years learning to identify the SIGECAPS symptoms, and it turns out, it's the economy that does people in? After reading that article, I wonder what I spent four years in residency for. Can someone tell me?

For starters, suicide isn't a DSM disorder and it is not always the result of psychiatric illness, so some of the problem is outside the traditional purview of psychiatry.

What you're saying, correctly, is that there are important risk factors beyond your control and beyond the level of the individual that influence risk of suicide. This perspective isn't unique to psychiatry. For instance, Dean Ornish didn't testify before the Senate because he attributed the burden of cardiovascular disease entirely to poor individual lifestyle choices.

Anyway, welcome to the intersection of psychiatry and public health! Not a new field, BTW: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518346/

 

[clausewitz2]

I have seen several patients (n=6) with with myxedema coma with psychopathology and in all of them the TSH was >100. Also in all but one case the raised myxedema coma was caused by psychiatric disturbance rather than the myxedema causing the psychiatric disturbance (of course they can also interact and I've seen that). Visual hallucinations in someone aged 70 might suggest delirium, but as this has gone on for a few months I would certainly consider the possibility of an underlying problem like late paraphrenia, lewy body dementia, or a substance-induced cause. a TSH of 30 is not all that impressive and although if there were other features that suggested significant decompensation (for example hypothermia, heart failure) due to hypothyroidism one might consider that the TSH is an issue. It usually takes several months before cognitive slowing improves with T4 to complicate things further. Although it is certainly possible that the patients psychiatric symptoms were due to hypothyroidism, it would be a mistake to chalk it up to that and not keep an open mind about the differential at this point. Particularly if the patient has a history of hypothyroidism - I would be very much inclined to think that there was something going on that caused the patient to stop taking her synthyroid and leading to this state. In addition although we are all told to think of hypothyroidism in dementia workup, and it can definitely cause cognitive slowing (quite dramatic in fact) the best evidence suggests it is usually an innocent bystandard when present in the context of cognitive impairment and should not blindside the clinician to another cause.

Yeah, the one real myxedema coma I have seen to date was in someone who had had their thyroid out years before and had presented to an ED waving tree branches at law enforcement and throwing their clothes into a ditch several states away from where they normally lived. Impressive stupor that did improve dramatically after a few days of synthroid but it because rapidly apparent after the family arrived from out of state that there was quite a lot going on prior to this and that a choice had been made at some point to just stop taking this long-established home dose of synthroid that had been adequate for years.

Anecdata for psychiatric disturbance causing this state +1

 

[Blitz2006]

I agree with you about some things - but I'm curious - why did Hem/Onc and cardiology get you involved about a QTc of 480? In my experience, well, first, if a medicine subspecialty is concerned about the cardiac implications of a psych med - they will just stop it, pronto, and inform psych later, if at all, in which case it's no longer a "consultation." And second, a QTc in the 400s is not that extreme. However maybe in this case it has something to do with the patient needing chemo? Can you say more about what prompted this multidisciplinary consult, and how it resulted in this rather conservative approach to the QTc?

I ask because when I was a 4th year psych resident, I finagled my way into a cardiology rotation. I specifically asked the cardiology attending "What do you think about these prolonged QTc's caused by psych meds - in the range of the high 400s - should we really be worried?" He said that is ridiculous - that cardiologists don't get worried about QTc until it's well into the high 500s. The literature on torsades de pointes (and V-tach more generally) is quite meager and does not justify getting worried before that, he said. Plus, a gazillion meds cause prolonged QTc, including many antibiotics. So it's not practical to just change them all.

After that rotation, I then went and made good on my off service experience by doing a little song and dance presentation to the psychiatry department about how we all should chill out about QTcs. But now you're saying that a 480 is super-worrisome? Can you say more please?

As far as capacity - sure,we do those evals, but the surgeons should be doing them. Preferably, psychiatry should never be consulted for capacity, since capacity evals can be done by any MD, ideally one who actually knows the risks, benefits, and alternatives to the treatment being proposed.

As far as course vs fine crackles, can you say more about why you consider lung sounds to be uninteresting, and yet are interested in psychiatry, where we have to ask patients on a daily basis whether their sleep disturbance is of the "delayed onset" vs the "frequent awakening" type? Sleep complaints are a mainstay of psychiatry, possibly its biggest mainstay. In order to appreciate sleep complaints, I have to use my ears, in order to hear the patient tell me what is wrong with their sleep. And generally they use one of a handful of descriptors, which include "bad," "ok" "restless," "not good," etc. I don't see how that is any different from trying to appreciate lung sounds, other than with lung sounds, I'd have to pay for a stethoscope in order to hear what's going on with the patient, and so I suppose you could argue that being a psychiatrist is about $200 less expensive than being an internist or pulmonologist. But either type of complaint, if you hear them 20 times a day for 40 years, is going to get boring. So can you say what it is that makes you not care about lung crackles but do care about psych complaints?

Also, if you find labs monotonous and don't like using a stethoscope, can I ask why you went to medical school?

Whoa, whoa, whoa.

I never said QTc of 480 is "super-worrisome". You're focusing wayyy to much on the QTc. The point of the story was that other teams needed our advice, in order for the patient to move forward with their treatment. I agree, 480ms isn't that high, I don't really flinch until I see it above 525ms. But like I said, for the chemo trial, they needed it below 450ms.

The great thing about this case, is that I don't even know if wellbutrin was the best choice. i actually wanted mirtazapine, but my attending felt that wellbutrin is even safer for QTc. We both reviewed the literature. I dont know, but her appetite was poor (obviously, with weight loss), so I figured remeron would be more useful. This is what I love about psych, its super stimulating and no algorithms like in medicine. For example, if a patient has C.Diff, just give Flagyl. End of discussion. Boring to me. (Of course unless the WBC is >14, kidney is messed, than vanc).

Well, I actually like sleep and am considering sleep fellowship, so i don't mind the sleep questions! Well because sleep complaints are always different from individual to individual, you will never get the same story 2x. Coarse crackles all pretty much sound the same. And so do fine crackles. And you're right, patients will say stuff like "bad", "ok", and be very vague. I mean, if a patient consistently says his sleep is "bad" for over 1 month, maybe he has an underlying sleep disorder? Who knows. This is what I enjoy, trying to get to the bottom of it. Much better than ordering a CXR, and seeing an opacity. Big deal.

You're joking right? You actually think everyone goes to medical school to check labs and stethoscopes? You think surgeons like checking labs/using steths? Come on, half the specialties, like Rads, Path, All Surgeons, Psych don't care about that stuff. People go into medical school to learn knowledge about the human body, and then apply it to make a diagnosis which is followed by treatment and management. Labs/Steth is just one angle of doing this. There is also history taking and imaging, etc. Back in the UK where I went to medical school, my MEDICINE attendings would say the best docs can diagnose 90% of their patients just on history. The labs, imaging, examination usually just confirm your suspicion and of course, for medico-legal reasons. In the UK, surgeons diagnose pancreatitis and appendicitis clinically, history and physical. Nobody orders CT Scans. We actually check for shifting dullness here, when a patient is distended. Not like here where everyone just gets CT A/P. I had a patient with a distended abdo on my ER rotation, I told the surgery attending my clinical exam, which included percussion findings and shifting dullness, and he was shocked that a psych resident knew all that. He was even more shocked when I said no need for CT A/P, just conservative management (IVF/NG/NPO). Of course, they got CT A/P, and of course, it was just post-op ileus and conservative management was all that was needed.

If you went to medical school to check labs and use a stethoscope, then you better get out of psych...ASAP.

 

[Shikima]

Faith??? I find it disturbing that you are likening a medical specialty to religious belief. But thanks for at least acknowledging that that's what we're talking about. I've been worried for quite awhile that psychiatry was plagued by pseudoscience, but it never occurred to me until now that, in fact, it's just a religion.

 

[temoojin]

As a little baby third year planning on going into psychiatry I wanted to say thanks for this thread and the wide range of views it contains. A lot of the time I think the forum paints the field in a light seen only through rose colored glasses. If a newspaper headline said, "The Best Psychiatrist in the World..." (however you want to qualify that), it would never be seen in the same light as, "The Best Surgeon in the World...". The populace is solipsistic, doesn't understand what the two do on the same level, and won't understand humans as both a person and a machine, each able to affect the other to the point of non-functioning. I personally like this fact, and I don't expect my profession in life to confer some sort 0f respect I feel I deserve.

 

[MacDonaldTriad]

I think there are plenty of places where psychiatrists can satiate their need to be all uppity and surround themselves with people who will kiss their ring. This is almost a defining characteristic of universities. These places aren’t as ubiquitous as they are for surgery, but if you really look at what is going on here, is it psychiatry that doesn’t deserve the respect of other physicians? Maybe, just maybe, the character flaws are in the other physicians who need to participate in this pissing match and insult our field. You can let this get you down, but it doesn’t take much self-confidence to see the jabs for what they are. Other doctors are very uncomfortable with the illnesses we manage. Their teasing is their insecurity more often than its ours.

 

[thoffen]

I think there are plenty of places where psychiatrists can satiate their need to be all uppity and surround themselves with people who will kiss their ring. This is almost a defining characteristic of universities. These places aren’t as ubiquitous as they are for surgery, but if you really look at what is going on here, is it psychiatry that doesn’t deserve the respect of other physicians? Maybe, just maybe, the character flaws are in the other physicians who need to participate in this pissing match and insult our field. You can let this get you down, but it doesn’t take much self-confidence to see the jabs for what they are. Other doctors are very uncomfortable with the illnesses we manage. Their teasing is their insecurity more often than its ours.

This +infinity.

We are, however, disadvantaged when it comes to operating within the medical model, and some of that disadvantage comes from us.

I liked consults, but decided to forego fellowship. Only once did I really get pissed off at someone consulting me. This was trauma surgery consulting me for "SI" because they had seen a psychiatrist and expressed it 2 years before, and when I asked if the patient was suicidal now, the resident said "what do you mean?", me: "What does she say when you ask her if she has thoughts of killing herself?", resident: "I didn't ask"... Still, all consulted specialties get this crap. Let me call neuro because someone is complaining of weakness, and not to have asked "where" or done my first crack at a neuro exam. Short of that, I found that a lot of the best consults were ones where the other person couldn't figure out what they were asking for. They just knew they needed help. And some of the more rewarding ones were where I helped facilitate the collaboration of the team or build bridges with family and did nothing for a patient. The "liaison" part of C/L gets forgotten about too often.

 

[MLT2MT2DO]

A psychiatry attending in my program was recently panicking over a CK value of 200.

An ER attending recently consulted me because she thought a 79 year old gentleman, due to ringing in his ears, was having a first break psychosis despite never carrying a mental illness dx.

What's your point?

Sent from my SM-G900V using SDN mobile

 

[doctorpilgrim]

So an individualized suicide risk assessment done in systemic manner which identifies modifiable risk factors is not good practice?

 

[Leo Aquarius]

A psychiatry attending in my program was recently panicking over a CK value of 200.

Maybe he or she had a reason to be worried.

 

[Ellaellafan]

Wow when I started this thread I didn't expect much response. But Thanks for keeping it interesting. Still figuring out what I'll do, but in the mean time enjoying my ride of being a psychiatrist. Interesting ride. Thanks all.

 

[Wilf]

Maybe he or she had a reason to be worried.

Can you give at least one example of why a knowledgeable physician would be very worried about a CK of 200 in a patient with no significant symptoms?

 

[FlowRate]

Well because sleep complaints are always different from individual to individual, you will never get the same story 2x

I've only spent ~10 full days in sleep clinic with two sleep neurologists, but in that experience I saw 33% the same story for OSA, 33% the same story for behavioral insomnia, and max 33% interesting other things and atypical presentations.

Short of that, I found that a lot of the best consults were ones where the other person couldn't figure out what they were asking for...

This is why I'm interested in CL The intepersonal side of systems medicine.

 

[Blitz2006]

I've only spent ~10 full days in sleep clinic with two sleep neurologists, but in that experience I saw 33% the same story for OSA, 33% the same story for behavioral insomnia, and max 33% interesting other things and atypical presentations.


This is why I'm interested in CL The intepersonal side of systems medicine.

You missed my point. I wasn't saying the actual diagnosis of OSA is exciting. I'm saying the way you get to the diagnosis in psych, is more stimulating for me. Of course once you see a sleep doctor, its pretty straightforward history. But taking a sleep history on an inpatient psych unit is much tougher (at least for me it is), and you are trying to decipher if its a sleep disorder or GAD or depression, etc. that is causing the sleeping issues.

Whereas listening to the lungs, fibrosis fine crackles will always pretty much sound the way. Whereas the history from a psych patient regarding his/her sleep will always be different, and personally, more stimulating for me.

 

[Blitz2006]

Can you give at least one example of why a knowledgeable physician would be very worried about a CK of 200 in a patient with no significant symptoms?

Yeah i agree, unless maybe the patient is on a statin?

But I dunno, upper limit is 225, so not sure if that should raise any eyebrows....

 

[FlowRate]

You missed my point. I wasn't saying the actual diagnosis of OSA is exciting. I'm saying the way you get to the diagnosis in psych, is more stimulating for me. Of course once you see a sleep doctor, its pretty straightforward history. But taking a sleep history on an inpatient psych unit is much tougher (at least for me it is), and you are trying to decipher if its a sleep disorder or GAD or depression, etc. that is causing the sleeping issues.

Whereas listening to the lungs, fibrosis fine crackles will always pretty much sound the way. Whereas the history from a psych patient regarding his/her sleep will always be different, and personally, more stimulating for me.

Am I understanding correctly that you're interested in sleep medicine as it pertains to the inpatient psych population?

 

[Blitz2006]

Am I understanding correctly that you're interested in sleep medicine as it pertains to the inpatient psych population?

No I'm interested in the neurophysiology and science behind sleep, as well as being able to one day interpret EEGs.

I was just using sleep as the example as nancysinatra mentioned sleep in her example, being 'mundane' to ask about. My argument is that taking a sleep history for me is more interesting/stimulating than listening to crackles. Thats all.

 

[FlowRate]

No I'm interested in the neurophysiology and science behind sleep, as well as being able to one day interpret EEGs.

I was just using sleep as the example as nancysinatra mentioned sleep in her example, being 'mundane' to ask about. My argument is that taking a sleep history for me is more interesting/stimulating than listening to crackles. Thats all.

My bad, I misunderstood. I thought you were talking about doing a sleep fellowship (to see patients who all present with unique histories.)

 

[Leo Aquarius]

Can you give at least one example of why a knowledgeable physician would be very worried about a CK of 200 in a patient with no significant symptoms?

We know a CK of 200 is nothing to jump at. I'm just saying perhaps give them the benefit of the doubt. I can imagine a wheelchair bound patient who had 2 prior CK values under 60 and then present with 200 causing a doctor to wonder a little. We all know levels of CK can rise after a heart attack, skeletal muscle injury, strenuous exercise, or drinking too much alcohol, and from taking certain medicines or supplements.

If you're trying to point out psychiatrists don't know medicine, that's another story.

 

[Shikima]

Consult: Assess and treat.

 

[Psyxh1]

I think we've all struggled with our limitations in helping people in psychiatry. That doesn't bother me as much as the worry that I'm causing iatrogenic harm whether it be with medications or diagnostic labels. I understand that people need help now and we know very little but it sill gets to me and makes me wonder about switching fields.

The above quote really is part of what unsettles me. Is it common and easy to cause iatrogenic harm with medications? For example, how do you know for sure that the antispsychotic didn't contribute to metabolic syndrome after a patient has been on it for 10+ years? I've always felt uneasy about diagnostic labels since many times they are just thrown about rather desultorily or in order to be paid for services. What can we do about this when patients are tainted for the long term after receiving a diagnostic label that might not even be true?

 

[Attending1985]

Antipsychotics and mood stabilizers have serious side effects. These can be mitigated somewhat and benefits usually outweigh risk when treating severe illness. There is some evidence the long-term antipsychotic use is not effective is certain patients. Antidepressants for most people do not cause serious side effects. There is some inconclusive evidence that treatment with antidepressants can worsen outcomes and cause a chronic course of depression as compared to no treatment. This I find concerning but for many reasons I don't know if this question will be answered in my lifetime. I think diagnostic labels can have a positive of negative effect depending on the patient and the diagnosis. The prevailing public opinion of mental illness, especially depression and anxiety, as a purely medical illness makes for a passive patient attitude that impedes recovery.

 

[smalltownpsych]

Antipsychotics and mood stabilizers have serious side effects. These can be mitigated somewhat and benefits usually outweigh risk when treating severe illness. There is some evidence the long-term antipsychotic use is not effective is certain patients. Antidepressants for most people do not cause serious side effects. There is some inconclusive evidence that treatment with antidepressants can worsen outcomes and cause a chronic course of depression as compared to no treatment. This I find concerning but for many reasons I don't know if this question will be answered in my lifetime. I think diagnostic labels can have a positive of negative effect depending on the patient and the diagnosis. The prevailing public opinion of mental illness, especially depression and anxiety, as a purely medical illness makes for a passive patient attitude that impedes recovery.

It makes me happy when I see residents questioning the current zeitgeist. Is that redundant? Anyway, we need more MDs and DOs who are aware of the limitations of psychotropics. Just as we need more psychotherapists that recognize that non-goal directed therapeutic listening only is insufficient treatment. I get way too many patients who say that my other counselor just listened and nodded and jotted down notes and way too many patients who have been tried on a host of meds and none really seemed to work. Typically, it's because medication is not really what is indicated for the case or if a medication is indicated, it is seen as the answer when it is actually only a small part of that answer. It is always great when someone's depression lifts from a trial of an ssri and that was all it really took for them, but those are the exceptions rather than the rule.

 

[Attending1985]

It's nice to have a place to talk about this. In my residency, people are not interested discussing it and don't seem to be concerned. Which I can't understand considering how poor statistical outcomes are.

 

[erg923]

Antipsychotics and mood stabilizers have serious side effects. These can be mitigated somewhat and benefits usually outweigh risk when treating severe illness. There is some evidence the long-term antipsychotic use is not effective is certain patients. Antidepressants for most people do not cause serious side effects. There is some inconclusive evidence that treatment with antidepressants can worsen outcomes and cause a chronic course of depression as compared to no treatment. This I find concerning but for many reasons I don't know if this question will be answered in my lifetime. I think diagnostic labels can have a positive of negative effect depending on the patient and the diagnosis. The prevailing public opinion of mental illness, especially depression and anxiety, as a purely medical illness makes for a passive patient attitude that impedes recovery.

Placebo effect is concern of mine with the commonality of SSRI/SNRIs treatment these days, as well as the vast over reliance on "sleep meds." Convincing my patients that this actually ****s up your natural circadian rhythm (in absence of non-psych sleep disorders) is very difficult.

I have patients who are convinced that they will literally never sleep again if they get off their 10 years of Ambien CR. Similar story regarding if they arent followed for the next ubteen years by a psychiatrist for their 20mg of Celexa. What a mess...

 

[Shikima]

Placebo effect is concern of mine with the commonality of SSRI/SNRIs treatment these days, as well as the vast over reliance on "sleep meds." Convincing my patients that this actually ****s up your natural circadian rhythm (in absence of non-psych sleep disorders) is very difficult.

I have patients who are convinced that they will literally never sleep again if they get off their 10 years of Ambien CR. Similar story regarding if they arent followed for the next ubteen years by a psychiatrist for their 20mg of Celexa. What a mess...

There is the Morin article which backs this up. JAMA. 2009;301(19):2005-2015.

However, don't dump on SSRI/SNRI therapy too much - I believe that it does help with encouraging plasticity while working in psychotherapy.

 

[Wilf]

for the next ubteen years

Malapropism.

 

[erg923]

Malapropism.

Yes, exactly.

 

[clausewitz2]

Yes, exactly.

Also acceptable term of indefinitely large reference: eleventy.

 

[clausewitz2]

It makes me happy when I see residents questioning the current zeitgeist. Is that redundant? Anyway, we need more MDs and DOs who are aware of the limitations of psychotropics. Just as we need more psychotherapists that recognize that non-goal directed therapeutic listening only is insufficient treatment. I get way too many patients who say that my other counselor just listened and nodded and jotted down notes and way too many patients who have been tried on a host of meds and none really seemed to work. Typically, it's because medication is not really what is indicated for the case or if a medication is indicated, it is seen as the answer when it is actually only a small part of that answer. It is always great when someone's depression lifts from a trial of an ssri and that was all it really took for them, but those are the exceptions rather than the rule.

Had a relative who recently told me all their therapist does is ask them how they feel about something they said. Obviously I did not engage with this, but I took this to mean they probably have a terrible therapist, if true.