Going crazy

[Can'tdecide111]

I need help deciding between Psych and IM. I applied to both because I couldn't really make a decision in what I wanted to do. I have interviews in both, but I'm really stuck in trying to figure out what I want to rank first.

My initial reason for going into medicine is because I enjoy being a chessmaster, able to treat whatever comes my way and make my patients feel good about their lives. That said, I've been considering:

IM: You are that chessmaster (or at least will strive to be for the next 20 years or however long you practice) and you aren't shut out of any field. Job security is amazing and patient , but the hours are often uncontrollable and burnout is rampant

Psych: You CAN be a chessmaster of mental health (or at least will strive to be for the next 20 years or however long you practice) but now you are limited to the mental health aspect of the field. You are shut out of doing fields like Cardiology, Pulm or Allergy, but you can still do Child, C-L or Forensics. Also I'm interested in Autism as a patient population that I would like to treat someday, but I feel like I will miss reading EKGs or interpreting labs/physical exam signs, etc.

This is really tearing at me and I need help to decide which field is best.

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[ThoracicGuy]

I need help deciding between Psych and IM. I applied to both because I couldn't really make a decision in what I wanted to do. I have interviews in both, but I'm really stuck in trying to figure out what I want to rank first.

My initial reason for going into medicine is because I enjoy being a chessmaster, able to treat whatever comes my way and make my patients feel good about their lives. That said, I've been considering:

IM: You are that chessmaster (or at least will strive to be for the next 20 years or however long you practice) and you aren't shut out of any field. Job security is amazing and patient , but the hours are often uncontrollable and burnout is rampant

Psych: You CAN be a chessmaster of mental health (or at least will strive to be for the next 20 years or however long you practice) but now you are limited to the mental health aspect of the field. You are shut out of doing fields like Cardiology, Pulm or Allergy, but you can still do Child, C-L or Forensics. Also I'm interested in Autism as a patient population that I would like to treat someday, but I feel like I will miss reading EKGs or interpreting labs/physical exam signs, etc.

This is really tearing at me and I need help to decide which field is best.

If you did im, would you be ok with never having a significant psych practice (Though there will be some)?

If you did psych, would you be ok with never doing im again?

 

[Can'tdecide111]

If you did im, would you be ok with never having a significant psych practice (Though there will be some)?

I can live with not having to be involved heavily with refractory psychiatric disorders in which initial treatment will not work. My interest in psych stems from wanting to treat Autistic disorders and make an impact there. Other psychiatric disorders, although interesting, don't really interest me to the point where I would necessarily want to go in depth.

That being said, I'm interested in the mental health aspect of care because I often feel like many of the medical problems do have a mental health aspect that needs to be addressed and learning to address that would be significant

If you did psych, would you be ok with never doing im again?

I would miss it. I love being a chessmaster. I want to be the guy who says "okay so this, this and this needs to be done" and therefore, do this, this and this." It would be cool for me to be that guy that is like a captain of a ship when it comes to patient care. I also want to deal with obesity as this is a rampant problem with 70% of the American public being overweight or obese.

Just that now, I'm screwed here, because I wanted to treat Autistic patients and now it may not be a main part of my practice. However, I am interested in fitness and I would love to counsel my patients on losing weight to resolve HTN, DM and obesity and can definitely see myself running a practice where I see those types of complaints.

Sorry if I'm typing paragraphs, but I'm really conflicted and perhaps if I say more, people might have more insight into what I should do than I hve.

 

[ThoracicGuy]

I can live with not having to be involved heavily with refractory psychiatric disorders in which initial treatment will not work. My interest in psych stems from wanting to treat Autistic disorders and make an impact there. Other psychiatric disorders, although interesting, don't really interest me to the point where I would necessarily want to go in depth.

That being said, I'm interested in the mental health aspect of care because I often feel like many of the medical problems do have a mental health aspect that needs to be addressed and learning to address that would be significant



I would miss it. I love being a chessmaster. I want to be the guy who says "okay so this, this and this needs to be done" and therefore, do this, this and this." It would be cool for me to be that guy that is like a captain of a ship when it comes to patient care. I also want to deal with obesity as this is a rampant problem with 70% of the American public being overweight or obese.

Just that now, I'm screwed here, because I wanted to treat Autistic patients and now it may not be a main part of my practice. However, I am interested in fitness and I would love to counsel my patients on losing weight to resolve HTN, DM and obesity and can definitely see myself running a practice where I see those types of complaints.

Sorry if I'm typing paragraphs, but I'm really conflicted and perhaps if I say more, people might have more insight into what I should do than I hve.

Would it be harder to build an Autism practice or an IM practice?

What sort of area of the country would you see yourself living in 10 years? (i.e. city vs suburban vs rural)

Also, would you be ok if you did Psych and had to deal with a bunch of these other disorders in addition to the autism patients?

Would you be ok if you did IM and had to treat all the other IM disorders besides HTN/DM/etc?

 

[UTsksk]

Had a friend with the exact same struggle. He ended up going IM to get at least a little of psych instead of no IM in the psych world. Did you try applying Med-psych?

You're just going to have to decide what are you willing to give up.

 

[Can'tdecide111]

Would it be harder to build an Autism practice or an IM practice?

What sort of area of the country would you see yourself living in 10 years? (i.e. city vs suburban vs rural)

Definitely suburban. I want to be close to the city, but not far.

IM practice is easier and I've been working on it for while. My parents and friends are well established in IM world, but I do have connections to psych. Autism practice, I would have to look for patients that want to be treated by me and I would probably have to compete with other well established specialists in that field.

Had a friend with the exact same struggle. He ended up going IM to get at least a little of psych instead of no IM in the psych world. Did you try applying Med-psych?

You're just going to have to decide what are you willing to give up.

I know. I might just do IM and then apply to Psych after I finish residency. >_>

Crazy I know.

Also, would you be ok if you did Psych and had to deal with a bunch of these other disorders in addition to the autism patients?

Would you be ok if you did IM and had to treat all the other IM disorders besides HTN/DM/etc?

To the first question, it wouldn't be bad for me to treat Schizophrenia or Bipolar. I love patient interaction and would love to be of service to patients of this population as they are victimized a lot.

To the second question, yes. Completely. I would love to be of service to patients suffering from pain disorders or cancer or patients recovering from surgery. IM is interesting because it's an endless ocean and learning about new things in general is fun for me.

 

[ThoracicGuy]

Definitely suburban. I want to be close to the city, but not far.

IM practice is easier and I've been working on it for while. My parents and friends are well established in IM world, but I do have connections to psych. Autism practice, I would have to look for patients that want to be treated by me and I would probably have to compete with other well established specialists in that field.



I know. I might just do IM and then apply to Psych after I finish residency. >_>

Crazy I know.

Here's a story about a clinic that utilizes both Primary Care and Psych in treatment of autism. Could be a model to look for a job.

https://spectrumnews.org/news/specialty-clinics-offer-complete-care-adults-autism/

 

[rokshana]

If you did im, would you be ok with never having a significant psych practice (Though there will be some)?

If you did psych, would you be ok with never doing im again?

Lol...I don't know about your clinics and hospitals but the psych component was not lacking for me!

 

[Can'tdecide111]

Here's a story about a clinic that utilizes both Primary Care and Psych in treatment of autism. Could be a model to look for a job.

"Jones, a family physician, spends a full hour with each person. This allows him to uncover medical issues that people with autism may not readily communicate. He has learned, for example, that constipation is common in adults with autism, particularly those who take antipsychotic drugs. Severe constipation often manifests as behavioral problems, he has found."

THIS! This is why I wanna train both in IM and Psych, because Autism also has a lot of medical problems that need to be addressed in a population like this as well. I would love to have both medical and psychiatric training in helping this population!

 

[ThoracicGuy]

Lol...I don't know about your clinics and hospitals but the psych component was not lacking for me!

My clinic certainly has its share of psych pathology, but I just send them back to their PCP for it!

 

[Can'tdecide111]

Had a friend with the exact same struggle. He ended up going IM to get at least a little of psych instead of no IM in the psych world. Did you try applying Med-psych?

You're just going to have to decide what are you willing to give up.

I didn't apply to those programs because initially I wanted to do psych, but at a friend's urging, I also applied IM. And now I'm conflicted.

 

[FutureInternist]

Answer is in the title.

Crazy —> Psych

 

[Can'tdecide111]

Answer is in the title.

Crazy —> Psych

lol so crazy should go into Psych?

 

[IMPD]

"Jones, a family physician, spends a full hour with each person. This allows him to uncover medical issues that people with autism may not readily communicate. He has learned, for example, that constipation is common in adults with autism, particularly those who take antipsychotic drugs. Severe constipation often manifests as behavioral problems, he has found."

THIS! This is why I wanna train both in IM and Psych, because Autism also has a lot of medical problems that need to be addressed in a population like this as well. I would love to have both medical and psychiatric training in helping this population!

Medicine treats tons of psych. Psych does not adjust blood pressure medicine and considers statins "complicated".

Medicine does not (usually) feel comfortable diagnosing anything other than depression, anxiety and grief. Thought disorders? No way. Fail your first SSRI? Refer to psych.

I'm generalizing, of course. But the reality is that Psych is a specialty and by design loses their ability/interest in treating general stuff. IM (can be) a generalist job. It really boils down to specializing in psych or having some psych to liven up your day in Medicine. Combined programs are not recommended by me, since (almost) no one practices both.

 

[Can'tdecide111]

Medicine treats tons of psych. Psych does not adjust blood pressure medicine and considers statins "complicated".

Medicine does not (usually) feel comfortable diagnosing anything other than depression, anxiety and grief. Thought disorders? No way. Fail your first SSRI? Refer to psych.

I'm generalizing, of course. But the reality is that Psych is a specialty and by design loses their ability/interest in treating general stuff. IM (can be) a generalist job. It really boils down to specializing in psych or having some psych to liven up your day in Medicine. Combined programs are not recommended by me, since (almost) no one practices both.

Can I be an Internist that can also specialize in the treatment of Autism? That is, have patients that are IM, but also see patients that suffer from ASD and address their medical and mental health concerns as well?

 

[IMPD]

Can I be an Internist that can also specialize in the treatment of Autism? That is, have patients that are IM, but also see patients that suffer from ASD and address their medical and mental health concerns as well?

Sure. You would do additional training, and not be Boarded in that. You'd have to collaborate with the Psych providers (if the patients have one). Med-Peds does more of this in my town. But General IM does pretty much whatever they want to. I know Psych that specializes in autism. They have a specialty clinic to deal with behavior issues. They don't do ANY of the medical part. Does that make sense? These kids often stay with their Pediatrician for a looooonng time because most general internists are not well equipped to see them. We have worked on a "transition to IM" program for a while, but it has not taken off. None of the players are motivated to transition the kids. Nevertheless, GIM offers many many chances to focus on the care of specific populations.

 

[Can'tdecide111]

Sure. You would do additional training, and not be Boarded in that. You'd have to collaborate with the Psych providers (if the patients have one). Med-Peds does more of this in my town. But General IM does pretty much whatever they want to. I know Psych that specializes in autism. They have a specialty clinic to deal with behavior issues. They don't do ANY of the medical part. Does that make sense? These kids often stay with their Pediatrician for a looooonng time because most general internists are not well equipped to see them. We have worked on a "transition to IM" program for a while, but it has not taken off. None of the players are motivated to transition the kids. Nevertheless, GIM offers many many chances to focus on the care of specific populations.

What additional training would I need to do? And also, if I'm not boarded in the care of Autistic patients, can I still prescribe the appropriate medications (SSRI, anti-anxiety, antipsychotics) and do appropriate counseling provided I'm working with a Psychiatrist/Psychologist? Is there some threat of malpractice? And if I wish to, could I participate in Autism research as a clinician to discover practices and treatment regimens that would be most optimal to this patient population?

If I can provide treatment/counseling without threat of malpractice and I can do research as well, I might just choose IM. That way I'm not cut off from the rest of medicine and I can render care to Autistic patients as I please provided I work with a Psychiatrist/Psychologist.

 

[ThoracicGuy]

What additional training would I need to do? And also, if I'm not boarded in the care of Autistic patients, can I still prescribe the appropriate medications (SSRI, anti-anxiety, antipsychotics) and do appropriate counseling provided I'm working with a Psychiatrist/Psychologist? Is there some threat of malpractice?

If I can provide treatment/counseling without threat of malpractice, I might just choose IM. That way I'm not cut off from the rest of medicine and I can render care to Autistic patients as I please provided I work with a Psychiatrist/Psychologist.

The psychiatrist would likely be managing the psych meds. You'd manage the rest. I'm sure that psych docs would love to have an adult IM doc that would want to manage these patients from a medical side of things on the long term.

I'm not sure what you mean about malpractice. There's always a 'threat' of malpractice in that anyone can sue you for anything. If they win or not may be another matter. But as an IM doc, doing some basic psych stuff isn't going to lead to an increased risk of malpractice from what I can see.

 

[Can'tdecide111]

The psychiatrist would likely be managing the psych meds. You'd manage the rest. I'm sure that psych docs would love to have an adult IM doc that would want to manage these patients from a medical side of things on the long term.

I'm not sure what you mean about malpractice. There's always a 'threat' of malpractice in that anyone can sue you for anything. If they win or not may be another matter. But as an IM doc, doing some basic psych stuff isn't going to lead to an increased risk of malpractice from what I can see.

Okay. I've decided. I'll probably rank IM first and then psychiatry. If I can still be of service to the Autistic population as a clinician by providing counseling and managing their medical issues, all of this becomes a nonissue. Also, I can still read EKGs and PFTs and manage obesity, HTN and DM as I see fit. I think I can also provide "therapy" in the sense that I can hear out the patient's grievances and implement bio-psycho-social interventions as a clinician. I can work with psychiatry for psychiatric medications and psychologist/social workers such that the patient is provided appropriate psychotherapy.

I think this makes the most sense. My goal is that the patients that I see who are on the Autistic spectrum improve their lives to the point where they are functional. If I can do this as a IM doctor through appropriate management and referrals, then that's pretty much the best path I can take.

 

[michaelrack]

If you want to treat primarily autism, you will need to do a peds and/or child psych residency.
There are not large concentrated populations of adult with autism waiting for you to treat, they are scattered around here and there. There are some adults with severe autism and comorbid MR in institutions for the ******ed, so I guess if you were interested in ******ation also you could do IM or adult psych.

 

[Can'tdecide111]

If you want to treat primarily autism, you will need to do a peds and/or child psych residency.
There are not large concentrated populations of adult with autism waiting for you to treat, they are scattered around here and there. There are some adults with severe autism and comorbid MR in institutions for the ******ed, so I guess if you were interested in ******ation also you could do IM or adult psych.

I'm sorry, but this doesn't make sense. Children with Autism often grow up to be adults with Autism. Autism isn't lost just because someone is an adult. And also specialty clinics for Autism exist as ThoracicGuy posted.

And from I know, there are unique medical problems have Autistic patients have to contend with which are unique. Also from what I know Autism lies on a spectrum between high and low functioning as well. I don't see why IM would be the wrong choice here as I would also get to manage HTN, DM and obesity and I wouldn't shut myself off to all the other interesting pathologies that I could see in the medical field.

Also if I DID make a mistake, I can always switch into a Psych program later or else do a Psych residency after IM. I don't feel like this is a mistake though.

 

[michaelrack]

from the article: "hospitals from other states would like to replicate the Neurobehavior HOME program but lack the funding". I guess if you want to specialize in IM and go into academia and then try to get a job at one of the few academic centers that have a specialized clinic like this, have at it.

 

[michaelrack]

I'm sorry, but this doesn't make sense. Children with Autism often grow up to be adults with Autism. Autism isn't lost just because someone is an adult. .

There are a lot more resources available for kids with autism than adults

 

[michaelrack]

I am boarded in both psych and IM, and it would be very difficult for me to find a job (especially outside of academia) taking care of adults with autism

 

[Can'tdecide111]

I am boarded in both psych and IM, and it would be very difficult for me to find a job (especially outside of academia) taking care of adults with autism

This is interesting. What do you think about being boarded in both? Do you feel like it gives you an advantage over someone only trained in one field or the other?

 

[WingedOx]

I can live with not having to be involved heavily with refractory psychiatric disorders in which initial treatment will not work. My interest in psych stems from wanting to treat Autistic disorders and make an impact there.

(I'll write a longer, more reasoned response later... gotta go home now).

 

[michaelrack]

This is interesting. What do you think about being boarded in both? Do you feel like it gives you an advantage over someone only trained in one field or the other?

In the short run, it is not much of an advantage other than some added flexibility (being able to pursue a job in either field). In the long run, it is an advantage and over time you can create positions or find part time positions that allow you to utilize both specialties and increase your income. I say in the long run, because in the short run it is hard to go out and find a job that utilizes both specialties.
As an example, I started my current main job as a psychiatrist at Panola Medical Center (Batesville Mississippi) in early 2015, and did just psychiatry. Later I picked up supervision of some family practice/acute NP's at Panola Medical Center. This helped me to keep current in IM and allowed me to pick up some extra $.

 

[24blue8]

Is this something that came to you suddenly? We hear your passion but it doesn't like you have really sat down and thought about this before going on all these interviews and applying for residency.

I agree that obviously adults with autism need and do receive care but your ability for maximum impact and exposure would be in a younger population. Have you considered genetics (as there's a subset of autism associated with genetic abnormalities)? You could do an internal medicine year then apply for genetics as a fellowship.
Additionally maybe consider switching to pediatrics and going into the field of developmental/behavior. I think that even has it's own residency now.

As it stands, child psychiatry and managing an inpatient unit where you review labs (on admission or as they arise) and get to prescribe things like insulin and simple antibiotics might help you accomplish everything you are setting out to.

 

[Can'tdecide111]

Is this something that came to you suddenly? We hear your passion but it doesn't like you have really sat down and thought about this before going on all these interviews and applying for residency.

I agree that obviously adults with autism need and do receive care but your ability for maximum impact and exposure would be in a younger population. Have you considered genetics (as there's a subset of autism associated with genetic abnormalities)? You could do an internal medicine year then apply for genetics as a fellowship.
Additionally maybe consider switching to pediatrics and going into the field of developmental/behavior. I think that even has it's own residency now.

As it stands, child psychiatry and managing an inpatient unit where you review labs (on admission or as they arise) and get to prescribe things like insulin and simple antibiotics might help you accomplish everything you are setting out to.

I also want to manage obesity, HTN and DM because I'm into fitness. I think I could at least start a IM residency and then consider what I want to do. I don't really want to close myself off to other fields of medicine and IM is the best for that. And it seems like if I want to treat Autistic population I can go find one of these specialty clinics and be a primary care provider. Psychiatry, while really interesting, shuts me off from the rest of medicine and that's not something I like.

 

[Crayola227]

I was heavily counseled by many in primary care that's it quite easy to tailor your practice for certain populations and medical problems that are generally considered "undesirable" by many in your own field

I wanted to do a lot of psych (at the level appropriate for the GP), and I was told that getting those referrals is easy - you make it known in the community you want those patients, and they will come to you, providers will happily refer and patients want to be wanted, word of mouth helps you get even more

also, in my state, the list of providers that can legally provide psychotherapy is enormous - reimbursement might be another issue, and I don't mean to upset the psychiatrist and psychologists in here, but there is plenty of that which is not inappropriate for a PCP to provide on lifestyle interventions and such

I expect as an IM outpt doc, if you take steps to be qualified and educated in addressing those with autism, and also psych issues, you can find ways to fill your panel with more than the average number

you will still need to see all-comers, of course

remember that the internist can see patients as young as 12 (when I was 12, I saw the same internist my mom did, cuz that was an OK thing in my community), and provided that they otherwise aren't better off in peds or don't have a number of peds-type issues, that is fine, in this case, as the community's "go to" PCP for autism, I suspect again you will gain patients

you can tailor your practice for anything, provided you recognize your limits, obtain more education (there are ways to do this as well that isn't just fellowship or being boarded), quick to consult where needed, network, and gain experience

provided you do these things, then the chances of malpractice sticking is less, if you stay within your scope of practice, but scope of practice is something you can safely expand to some degrees depending on how you go about it

also I have heard of IM docs working in clinic with peds, that is how some IM docs gain exposure to make treating adolescents more appropriate

possibly you could create a relationship or ties with a developmental peds clinic (they handle most of the autism and MR patients in my area) and could gain patients and more education that way as well

 

[Crayola227]

as PCP you are usually first line for treating basic psych conditions
frequently the first docs to address depression and suicidal ideation

you get to do tons of wellness counseling for substance abuse disorders, one doc I know runs a suboxone clinic, and they do group counseling sessions that they lead
counseling for fitness, I know GPs that do quite a bit of sports medicine, helping people train for marathons, other sports, body building (safely), nutrition
counseling for obesity, which frequently involves more than just nutrition or exercise education, lifestyle modifications, you can get into some deep psychological stuff
when you address musculoskeletal complaints I find there's a lot of room for wellness education
same for addressing sleep complaints

much of this is bread and butter

for autism, you absolutely could learn enough to offer basic advice on all sorts of things

one of my close family members has nonverbal autism, and is an adult

they are not an extremely difficult to manage case for their caregivers, their GP manages their birth control, nutrition, picky eating, behavior issues, etc

I don't suggest cowboy medicine, but it's easy in this day and age to act like the only ones who can do anything are uber uber super specialists - that's great, and there's definitely plenty of times for the GP to refer up, still

 

[mvenus929]

Can I be an Internist that can also specialize in the treatment of Autism? That is, have patients that are IM, but also see patients that suffer from ASD and address their medical and mental health concerns as well?

I'm peds, but one of my continuity clinic attendings in residency 'specialized' in autism, in that he made it known in the community that he had an interest in autism, and patients were referred to him for the management of such. So yeah, I imagine you can do the same thing in IM.

What additional training would I need to do? And also, if I'm not boarded in the care of Autistic patients, can I still prescribe the appropriate medications (SSRI, anti-anxiety, antipsychotics) and do appropriate counseling provided I'm working with a Psychiatrist/Psychologist? Is there some threat of malpractice? And if I wish to, could I participate in Autism research as a clinician to discover practices and treatment regimens that would be most optimal to this patient population?

If I can provide treatment/counseling without threat of malpractice and I can do research as well, I might just choose IM. That way I'm not cut off from the rest of medicine and I can render care to Autistic patients as I please provided I work with a Psychiatrist/Psychologist.

There is no 'Board of Autism'. It's not like Endocrine, GI, Pulm, etc where there is a subspecialty board that monitors the providers in care. You (presumably) will be board certified to manage the diseases of adults if you do IM, and managing simple psychiatric conditions falls within that scope of practice.

As far as malpractice, almost all physicians get sued once in their careers, some multiple times. You aren't more likely to get sued if you are doing medical management of things. And you can always do research, provided you have an IRB and funding to do so, which will be easier to obtain in an academic setting.

I also want to manage obesity, HTN and DM because I'm into fitness. I think I could at least start a IM residency and then consider what I want to do. I don't really want to close myself off to other fields of medicine and IM is the best for that. And it seems like if I want to treat Autistic population I can go find one of these specialty clinics and be a primary care provider. Psychiatry, while really interesting, shuts me off from the rest of medicine and that's not something I like.

FWIW, peds sees a lot of obesity, HTN, and diabetes as well. Both my med school and residency hospitals have a 'fitness clinic' where children with obesity are sent. It's not exclusive to adult medicine, and you're probably more likely to make a change in peds.

 

[rokshana]

FWIW, peds sees a lot of obesity, HTN, and diabetes as well. Both my med school and residency hospitals have a 'fitness clinic' where children with obesity are sent. It's not exclusive to adult medicine, and you're probably more likely to make a change in peds.

that is just sad.

 

[mvenus929]

that is just sad.

It's also a relative thing. IM is almost exclusively one or all of those three things. In peds, probably 20% of my population is overweight or obese, a very small number has true hypertension (because they haven't been obese quite long enough to have bad CV system yet), and a slightly higher number have diabetes. But our endos see at least one patient with T2DM or obesity per day (when they're in general endo clinic, anyway). And probably some T1DM patients who now have insulin resistance too.

 

[Apollyon]

And probably some T1DM patients who now have insulin resistance too.

How does that happen? Or, can it even happen? I ask as a type I diabetic, dumb ER doc. As I tell the patients, I was never 300 lbs, drinking 3L of Mountain Dew a day - I'm just genetically inferior!

 

[mvenus929]

How does that happen? Or, can it even happen? I ask as a type I diabetic, dumb ER doc. As I tell the patients, I was never 300 lbs, drinking 3L of Mountain Dew a day - I'm just genetically inferior!

The ones who become 300 lbs, drinking 3L of Mountain Dew a day despite being type 1. Also, puberty inherently has some degree of insulin resistance, and a lot of teens especially put on a significant amount of weight once they are on insulin.

"The interactions between obesity, autoimmune processes, and glucose homeostasis are a growing field of study. In 2001, the Accelerator Hypothesis postulated that excess adiposity increases insulin resistance, leading to glucotoxicity and accelerating b-cell apoptosis, which increases immunogenicity in at-risk individuals, resulting in overt diabetes mellitus [14]. It posits that type 1 and type 2 diabetes are both disorders of insulin resistance that flank two extremes of a diabetes spectrum [14,15]."
Obesity, insulin resistance, and type 1 diabetes mellitus. - PubMed - NCBI

 

[Apollyon]

The ones who become 300 lbs, drinking 3L of Mountain Dew a day despite being type 1.

See, if I did that, I would be a blind, impotent, ESRD amputee, and dead at that.

 

[Can'tdecide111]

(I'll write a longer, more reasoned response later... gotta go home now).

Was waiting for this response, but I guess I'll be kept in suspense still.

I have a question. Can PCPs legally provide psychotherapy if they wish? Is it possible to provide this service? Or do you have to be a psychiatrist?

 

[gutonc]

Was waiting for this response, but I guess I'll be kept in suspense still.

I have a question. Can PCPs legally provide psychotherapy if they wish? Is it possible to provide this service? Or do you have to be a psychiatrist?

A vascular surgeon can legally provide psychotherapy. It's probably not a great idea. But there's no law against it.

 

[Crayola227]

Was waiting for this response, but I guess I'll be kept in suspense still.

I have a question. Can PCPs legally provide psychotherapy if they wish? Is it possible to provide this service? Or do you have to be a psychiatrist?

some states, yes, the MD and unlimited license makes this possible legally speaking. I know because I checked with my own board.

I can't say if this is a good idea or not

 

[LucidSplash]

A vascular surgeon can legally provide psychotherapy. It's probably not a great idea. But there's no law against it.

So many of my patients are a bit nuts, so it’s good to have a wide-ranging skill set I guess.

 

[rokshana]

How does that happen? Or, can it even happen? I ask as a type I diabetic, dumb ER doc. As I tell the patients, I was never 300 lbs, drinking 3L of Mountain Dew a day - I'm just genetically inferior!

there are people that have insulin resistance as well as auto immune mediated diabetes ...not common, but not uncommon...clue can be a very high (.7- 1.0 units/kg/day) use of insulin for someone that had been dx as DM1. For these pt, metformin can be helpful to decrease the resistance.

 

[mimelim]

A vascular surgeon can legally provide psychotherapy. It's probably not a great idea. But there's no law against it.

I provide psychotherapy every week. Mostly for our patients, but sometimes for junior residents...

 

[hamstergang]

Can PCPs legally provide psychotherapy if they wish? Is it possible to provide this service? Or do you have to be a psychiatrist?

I would not go into IM with any expectation that you'll be able to become competent at psychotherapy. Learning to do it correctly takes a lot of time working with many patients and ongoing therapy supervision. It's possible to get this, but it's too unlikely for you to bank on it.

Also, even if you can legally do it, I don't know that insurance would reimburse you for it.

 

[Gastrapathy]

Or that your malpractice carrier will think it’s cool.

 

[Apollyon]

I can't say if this is a good idea or not

I can. As others have stated, it's not.

 

[Crayola227]

I can. As others have stated, it's not.

I think I'm thinking of motivational interviewing. The time isn't always taken to do it, but it's appropriate for generalists to do. I guess I think of a lot of patient education, interaction, as therapeutic, even psychologically so.

But no, none of this is probably what is *really* psychotherapy and I was being a bit rhetorical or sarcastic saying "I can't tell you if it's a good idea or not."

Because the point is, yes, you can "counsel" patients, and no one is going to stop you, so you have to figure out what is appropriate and what isn't. I can't tell someone because it's up to their training, experience, comfort level, and the situation, to figure out if what you're doing is too much or not enough.

I'm not in the camp that generalists do nothing that looks like counseling, but it isn't psychotherapy, I'm pretty sure. I'm not even sure what that is, but I know my medical board would let me do it And no, I don't think it's a good idea I do it. I know that much.

 

[mimelim]

I would not go into IM with any expectation that you'll be able to become competent at psychotherapy. Learning to do it correctly takes a lot of time working with many patients and ongoing therapy supervision. It's possible to get this, but it's too unlikely for you to bank on it.

Also, even if you can legally do it, I don't know that insurance would reimburse you for it.

Insurance would reimburse you, no different than any other provider that submits a bill. The issue would be credentialing and recruitment of patients, not legality or billing.

 

[Crayola227]

Insurance would reimburse you, no different than any other provider that submits a bill. The issue would be credentialing and recruitment of patients, not legality or billing.

Mm, in some states don't need credentials beside the MD and a license. As I understood it, some insurances can balk at bills submitted by those who aren't BC/BE. I guess I assumed that would be related to the type of thing they were billing for, but perhaps as long as you are boarded in SOMETHING they don't care that a vascular surgeon submits a bill for psychotherapy?

 

[NotAProgDirector]

A vascular surgeon can legally provide psychotherapy. It's probably not a great idea. But there's no law against it.

And a psychotherapist can legally perform vascular surgery. Equally bad idea.