Geri psych - the black sheep of fellowships?

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philosophize

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About half way thru intern year and to my surprise, i have really enjoyed my geri psych rotation and working with the geri population. Searching thru this forum, it seems like geri psych doesn't get much attention. I'm hoping to hear from practicing psychiatrists about their (or their friends') experience working with the geriatric population, in geri psych inpt units, or nursing homes? The good the bad the ugly ... I want to hear it all!

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I, like you, didn't give geriatric psychiatry much thought. On an inpatient sub-i I was assigned to the mostly geriatric psych team. I ended up really enjoying the mixture of neurology and psychiatry. It was intellectually stimulating, and challenging because treating the end stage dementia patients are always changing their baseline. In addition, treating mood disorders in geriatric patients was similarly rewarding, as many of them had lived deep, interesting, and inspiring lives.
I've been pretty moved by most of my psych rotations, but it was, much like your case, surprising to me how much I liked it.

From what I've been told on the interview circuit, a lot of spots in fellowships go unfilled, especially in geriatric psychiatry. If you like it, then there are SO MANY people just waiting to see you on the other side of residency. That has to feel good.
 
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Here is a year of geri fellowship in a nut shell:
1. start low and go slow
2. If you admit a geri patient with delirium, stop everything, watch them get better and carefully put one or maybe two meds back.
3. The social work part is often 90% of the work.
4. Don't be stingy with neuro consults. If a patient responds funny, ask for help.
 
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Has anyone run across any residencies with strong exposure to geri-psych built into the categorical program?
 
I really enjoyed my stint in psychogeris. One of the jobs was on a specialised MDT that did secondary consults for nursing home patients, and while most of it was managing BPSD, delirium or rationalising medication regimes, there were a few interesting cases that came up every now and then. On that particular job we also had to do some geriatric medicine cover shifts, which at times was a good refresher. One thing I recall was that there was very little in the way of severe personality disorders which was a nice change from the usual. Also, most patients in that age group were generally very polite and respectful of doctors - although I'm not sure if this will remain the case with the babyboomer generation.
 
Has anyone run across any residencies with strong exposure to geri-psych built into the categorical program?

I don't know if it fits the bill for your purposes, but at UPMC we do 8 weeks on a dedicated 40-odd bed geri unit as a mandatory part of our PGY-2. What is nice about it is that at our institution the neurology PGY-4s also have to rotate through it, so you end up learning a lot and have convenient almost-neurologists close at hand. Also a team of PAs to help with the medical issues, though sometimes a mixed blessing if you are trying to learn how to cope with that side of things in practice.

EDIT: Also a month of our inpatient medicine in Intern year is spent on an academic-ish geriatric service at a community hospital, which is of course terribly relevant if you are interested in geripsych.
 
Here is a year of geri fellowship in a nut shell:
1. start low and go slow
2. If you admit a geri patient with delirium, stop everything, watch them get better and carefully put one or maybe two meds back.
3. The social work part is often 90% of the work.
4. Don't be stingy with neuro consults. If a patient responds funny, ask for help.
5. ECT, ECT, ECT.
 
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I did not do a geriatric psychiatry rotation during residency, nor did I do a geriatric psychiatry fellowship but I style myself as a specialist in geriatric psychiatry and neuropsychiatry. Most of the geriatric fellowships are a waste of time anyway. You can certainly choose, if you go to a decent residency program, to focus on seeing geriatric patients.

I really enjoy working with the geriatric population. The population is ageing and there is great demand for psychiatric services for older populations. 80% of over 65s receiving treatment for "depression" in primary care do not actually have a major depressive disorder! Patients with dementia or other older patients with high risk of delirium are commonly prescribed benzodiazepines and other deliriogenic sedative hypnotics or psychotropics that increase their risk of depression. Few people are providing psychotherapy for older adults, many of whom would benefit from it. Our country is ill-equipped to deal with the ageing population of drug addicts and alcoholics who are now living into old age, and who are ending up in nursing homes. Dementia, while on the decline, continues to be a leading cause of the global burden of disease. Many patients are being misdiagnosed as having dementia, when they have treatable medical conditions. As the family structure breaks down and the traditional support systems fragment, older people are increasingly reliant on social or medical services. After pain, psychological symptoms are the major cause of suffering in end of life care - existential angst, anxiety, depression, loneliness, agitation, delirium, fatigue, and so on are. Because older patients have multiple medical comorbidities, it can be even trickier to treat their psychiatric issues pharmacologically thus requiring a strong grasp of psychopharmacology and medicine. Because of the multiple aspects of care, strong interdisciplinary working is the rule. Because of prevalence of neurodegenerative disorders in this population a good understanding of neurology and brain-behavior correlates comes in handy. Unlike most psychiatric patients, many geriatric patients have true brain diseases.

Some of the most fascinating conditions in psychiatry and disorders of later life - Charles Bonnet Syndrome, Posterior Cortical Atrophy, Lewy Body Dementia (where you see quite frank visual hallucinations), corticobasal syndrome (where you see alien limb phenomena), semantic dementia, late paraphrenia, bipolar dementia, punding and pathological gambling in parkinson's disease etc...

Also patients with vascular dementia in particular tend to develop delusional disorders including erotomania, Othello syndrome, delusional parasitosis etc

A good residency program should provide the flexibility to give you training emphasising work with older adults.
IMHO, a good fellowship (if one exists) should provide training in outpatient, inpatient, consulation, nursing home and day hospital settings. It should include rotations in movement disorders, sleep medicine, dementia (including young onset dementias), palliative medicine, and ECT. There should be training in sexual aspects of geriatric medicine and psychotherapy adapted to this population. The fellowship should also provide training in forensic issues including medical decision making capacity, testamentary capacity, financial capacity, undue influence, guardianship, elder abuse.

Contrary to the above, geriatric psychiatry is not "social work" (general psychiatry could similarly be denigrated in this way). While it is of course the case as it is for psychiatry and much of medicine in general that social aspects of care are far more important than the medical, that does not in anyway mean that there is not an important role for the physician in the care of these patients. This includes identifying too much care, reducing polypharmacy and other iatrogenic hazards, managing disruptive behavior, helping patients identify and meet goals, allow patients to stay in their homes for longer, providing support to families in complex cases, discussing genetic issues (related to inherited dementias), and relieving treatable suffering. While it is true that many conditions in the older population are incurable, degenerative, and even incurable, there are other conditions for which these patients respond marvellously. late paraphrenia and the involutional psychoses tend to respond better to treatment than the psychoses of childhood and early adulthood. The melancholia of old age (including delusional depression and catatonia) can respond very well to ECT. Older patients may be more ready to respond to psychotherapy and reflect over their past as it comes to haunt them in late life.

Before geriatric psychiatry, confused older people with neuropsychiatric disorders were consigned to the scrap heap. Geriatrics is one of the only areas in psychiatry where diagnosis actually matters. There was no effort to distinguish delirium, dementia, pseudodementia, or paraphrenia and thus treatable causes of "dementia" were going unchecked. This is still happening. I regularly see patients being misdiagnosed as demented when an underlying medical condition led to delirium, or a treatable depression has been missed. This has farreaching consequences and leaves older adults vulnerable to abuse and exploitation, financially and sexually. Whether you dx someone with bipolar, schizophrenia or schizoaffective disorder is inconsequential. But missing a diagnosis of pseudodementia or delirium in a patient presenting with "dementia" loss makes all the difference.
 
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The only fellowships necessary in psychiatry are child and forensics. Everything else (eg, gero C/L, addiction) is a waste of time/potential income and really only exists so psychiatry can keep up with the "rat race" of sub-speacialization of other fields (though without the increased clinical knowledge) and so the fellow can do all the work while the attending bills.
 
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The only fellowships necessary in psychiatry are child and forensics. Everything else (eg, gero C/L, addiction) is a waste of time/potential income and really only exists so psychiatry can keep up with the "rat race" of sub-speacialization of other fields (though without the increased clinical knowledge) and so the fellow can do all the work while the attending bills.

And obviously pain and sleep fellowships
 
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The only fellowships necessary in psychiatry are child and forensics. Everything else (eg, gero C/L, addiction) is a waste of time/potential income and really only exists so psychiatry can keep up with the "rat race" of sub-speacialization of other fields (though without the increased clinical knowledge) and so the fellow can do all the work while the attending bills.

Although I have some attendings telling me that in 10 years CL or Addiction fellowships will be required to work in an academic setting? Some truth to that or just hype?
 
Although I have some attendings telling me that in 10 years CL or Addiction fellowships will be required to work in an academic setting? Some truth to that or just hype?
you can still get addiction medicine certification without fellowship if ypu reslly want to. There will never be enough psychosomatics trained people for academic centers to be picky and as c/l expands it bexomes harder still. only the top NE hospitals seem to require psm certification for c/l jobs and possibly stanford (though i havent looked at Stanford as they pay so terribly but they claim to want it) None of the other west coast hospitals require psm certification to staff their c/l service. forensics, geriatrics or addictions training would do nicely for the c/l service. since fellowship training is a marker of masochism, academic centers certainly prefer fellowship training though the actual fellowship maters less
 
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How do you get addiction medicine certification without fellowship?



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you can still get addiction medicine certification without fellowship if ypu reslly want to. There will never be enough psychosomatics trained people for academic centers to be picky and as c/l expands it bexomes harder still. only the top NE hospitals seem to require psm certification for c/l jobs and possibly stanford (though i havent looked at Stanford as they pay so terribly but they claim to want it) None of the other west coast hospitals require psm certification to staff their c/l service. forensics, geriatrics or addictions training would do nicely for the c/l service. since fellowship training is a marker of masochism, academic centers certainly prefer fellowship training though the actual fellowship maters less

This makes no sense at all. If I am running a department, why should I give a **** if the consult attending did a one year, meaningless fellowship (aside from maybe MGH because they take pride in how prestigious their C/L psychiatry service is according to a friend who is a resident there)? Any competent psychiatrist (particularly one on the faculty at an elite northeast program) should be more than capable of doing C/L psychiatry with a general residency training (hence why the fellowship is pointless in the first place), especially since it will hardly make the department any money. I would think a department chair would MUCH prefer someone with tons of NIH money who agrees to do their clinical time on the C/L service... or someone who has a lot of funding for C/L type research.


How do you get addiction medicine certification without fellowship?

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Again, this is pointless as a psychiatrist. As a psychiatrist, if you want to specialize in addiction, if your residency doesn't teach you how to use Bup you can learn in an 8 hour course (which you need anyway unless you do the pointless AAAP fellowship). Any decent residency program should give you the basics of CBT, MI, 12 Step facilitation, group therapy etc, and the therapists who work with you will be the ones doing it in a more intensive form anyway. And keep in mind there are PLENTY of addiction psychiatry jobs (that don't require fellowship). If you want to do addiction research, then do a post doc with a strong mentor.
 
This makes no sense at all. If I am running a department, why should I give a **** if the consult attending did a one year, meaningless fellowship (aside from maybe MGH because they take pride in how prestigious their C/L psychiatry service is according to a friend who is a resident there)? Any competent psychiatrist (particularly one on the faculty at an elite northeast program) should be more than capable of doing C/L psychiatry with a general residency training (hence why the fellowship is pointless in the first place), especially since it will hardly make the department any money. I would think a department chair would MUCH prefer someone with tons of NIH money who agrees to do their clinical time on the C/L service... or someone who has a lot of funding for C/L type research.
I'm just telling it like it is. It's probably because it's the swines who run the psychosomatic services at the top academic centers in the NE are the ones who tried to sell the idea of "psychosomatic medicine" as a subspeciality needing fellowships and certification in the first place and thus they lead by example in demanding it. Maybe they have drunk their own kool aide. Maybe they really believe it. It is what it is. I can tell you the main C/L guy at my residency told me the fellowship was a waste of time but when he was APM President said that fellowship should be the standard in the field... It's all empire building
 
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thanks for the input guys, there's a lot of good info on here (despite a little circumstantiality there about the conspiracy of fellowships)
 
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