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Discussion in 'Psychiatry' started by drahc, Jan 20, 2018.
OP hasn't been back on this site since making his one post starting this thread many months ago.
Are you a Psych resident? How has your views on psych changed?
I am not. I am applying however.
I think I realized there are multiple dimensions and specialties within psychiatry proper. Likewise I learned that psychiatry is inherently an awesome field and that we have so much time to sit down and listen to patients and really get a comprehensive understanding of their psychopathology. I also like that I feel like there's a lot of research to be done.
This thread should be on the sticky board. Splik's response is GOLDEN and one I plan to reread from time when a little pick-me-up is called for. help...struggling with feeling ok in psychiatry
Warning, my own personal experience lies ahead:
I hit a bump in the road a few months back during PGY3 with refractory outpatient cases, heaps of end-stage personality dysfunction patients, never-ending streams of paperwork, disability, Rx and PA request BS, MyChart messages, minutes long crisis-no-not-really-a-crisis voicemails, patient family members with unrealistic expectations, etc. The burn was getting the best of me and every day seemed dreaded by dawn and celebrated at dusk. I found myself questioning the field in general or at least my place in it especially when very few seemed to benefit and this mindset percolated through the outpatient resident space.
After some introspection and questions regarding my demonstrated commitment beyond external expectations ("had I fully surrendered to this?") I decided to dive deeper into my studies- psychopharmacology and psychotherapy alike- which at least for me allowed the opportunity to become more curious in those refractory cases (or at least give myself a sense of hope, false or otherwise). I've attempted to convince myself (with some degree of success) that I could be that ONE person that seemingly obnoxious borderline-blackbelt comes across who responds with equanimity and curiosity as opposed to the countertransference precipitated knee-jerk reaction they so often experience.... one that has the power to wear a provider down to a nub if not aware of his own personal stuff. (Makes me think of that scene in the Sopranos pilot episode when Tony spoke of his mother with Dr. Melfi, his psychiatrist: "My dad was tough--he ran his own crew. Guy like that, my mother wore him down to a little nub. He was a squeakin' little gerbil when he died").
A psychotherapy supervisor's comment about being interested and fully-present with our patients also struck a chord and often echoes internally during those moments when that developing psychiatrist spidey sense starts tingling from impending personality-dysfunction "danger." Early on that tingling simply induced my own frustration and feelings of helplessness which only yielded existential strife ("What am I doing working here? Why? For what purpose? No one is getting better!") and pushed me even further from that fertile ground of shared-space necessary for healing. Becoming more mindful of my own internal reaction in the moment and approaching the more difficult cases with the intention of remaining aware and being fully present for my patient has been very helpful; it seems to be an act of mindfulness similar to the noting techniques used during insight training in certain meditative disciplines. (Vipassana worth of look for those who seem interested).
How much all of this will yield from a strictly clinical perspective (i.e. measurable results, remitting patients) or how my endurance will benefit for the long-haul remain to be seen but I find myself looking forward to my work more often and with greater vigor. I simply do not see any other approach for myself. Fully surrendering to the process and going all-in seems to be the only way... for me. "Ain't no such thing as half-way shrinks."
I like your thinking. It does make me question though to what end. Many med students and undergrads read this forum and are looking for honest apppraisals. If we have to try so hard to make it work is it worth it? Other specialties can just show up, do the work, get results and feel good.
Just a patient, but this seems like a little bit of magical thinking in terms of the conclusion that other specialties "get results" and "feel good." They don't, necessarily, and they generally don't have the training to cope with the patient who in addition to what may well be a chronic, untreatable, or unclear medical issue may also have a personality disorder, depression or something else that makes them a "difficult" patient.
Clearly, you and I had very different experiences on other services.
Grass is greener at its best. Other specialties have to deal with plenty of futility, tough patients, and medical inaccuracies/inefficiencies. The ones that just "show up" aren't the ones that "feel good," nor are they the ones that do right by their patients. Every physician needs to work hard to enjoy at least some aspect of their jobs and has to trust in their limits/the limits of current medical knowledge to some degree just to get through their day.
I’m comparing my experience to my spouse who works in urgent care or my dad a pediatrician. They both have much more opportunity to solve problems and many non personality disordered appreciative patients. They would both say this as well. Yeah they have difficulties here and there but it’s not the breadth of their work. This is just reality and why psychiatry is very difficult in its own right.
Perhaps my viewpoint would be different if all I saw were patients with ASPD or BPD, but my clinics are usually at least 50/50. I get what you're saying, but I guess I don't think its the breadth of psychiatry either. My multiple physician family members and close friends in other fields have plenty to complain about in terms of patients and futility as well, so I guess my experience doesn't feel all that unique.
My med school roommate in peds sees back to back to back viruses all the time. Hydrate and rest. Plenty of well children. Plenty of constipation recommending otc miralax. He can spend the majority of the day reiterating basic care.
ER friend is frustrated all the time. Why are you in the ER for a pregnancy test? Blood pressure is not an emergent issue, go home. Quit sticking things in your orifices. It’s a virus but I need higher press ganey scores so here is an abx to treat nothing.
Every field has its problems.
I know your posts were not in agreement with me but I see them as supportive of my view on things. In peds, you give reassurance and guidance the problem resolves. All is well and parents are appreciative. In ER, you give the pregnancy test, refer back to primary care, ect. These problems have a definitive answer. Compare that to a patient coming to with common problems in psychiatry (poverty, loneliness, relationship dysfunction, ect). These problems don't have definitive answers and won't get better on their own.
That awkward moment when a patient suggests OP is schizotypal.
Magical thinking != schizotypal, not by a long shot. Cf. Joan Didion.
Still not true. I do evaluations where I merely provide reassurance that the response is normal. I provide counseling for loneliness, relationship problems, career issues, etc. I provide parental training on behavioral issues. It is quite successful.
The vast majority of my patients experience significant improvements and many go into remission or are cured depending on how you personally view it.
Twas a joke because 'magical thinking' is one of the step 1/2 buzzwords for schizotypal lol. Haven't read that book, but I loved Slouching Towards Bethlehem. I'll have to pick it up.
Also 100 years of solitude, but that's magical realism.
I commend you for providing quality work. I wish this was the standard of care. Things would be different.
There seems to be a pervading mentality (fantasy?) amongst those entering medicine of some turnkey ideal (undergrad degree-> MD/DO--> complete residency--> BC--> now just show up and do my thing) whereas in reality the process should never cease until one stops practicing (hence the term). I could see one's "practice" remaining quite superficial (or even detrimental?) without digging deep and fully surrendering to the notion that to reach a truly competent level (forget about mastery) one needs to make this more than a 9-to-5 and instead one's lifework worthy of continued sacrifice... even after/when the system no longer demands it, extrinsically speaking. I would like to think this is the case for all physicians, regardless of specialty, although psychiatry offers (forces?) the opportunity to approach the psychosocial domain in a well-informed intentional manner as means of treatment.
This is a challenging field... one that could make folks miserable if not chosen with a clear understanding of what awaits. My fear is that many students are baited with the relatively friendly work hours (both in residency and beyond) and neon-sign words like 'lifestyle' and 'competitive' being thrown around without understanding the personal and professional demands necessary to achieve success and contentment. The typical medical student experience does not tend to elucidate this truth especially when many may simply compare their 4-6 weeks to the 12 they just had on a demanding inpatient medicine service.
Personally, I did not feel the burn until this year as a PGY3 and part of that being due to actually managing cases on my own (although with the help of great supervision) as opposed to being on inpatient when the attending still captains the ship, even when you're "carrying" your "own" patients. PGY3 is a nice taste of real world psychiatry to some degree and one that you simply won't know first-hand until you're actually there in the thick of it.
I digress, I hope more med students read these forums and realize this is far from a walk in the park. Like you said, to make it work... for our patients and for ourselves... we have to try hard... VERY HARD... and beyond residency at that. Without doing so you are either going to be a $#!++y doctor or a non-content (maybe miserable) one... maybe both.
Outpatient really drove home for me the idea that the minute I get comfortable and stop trying to challenge myself and keep getting better as a psychiatrist is the minute I start on the road to sucking at my job. I have seen too many people who peaked in residency, basically, and that ain't gonna be me.
Joan Didion was what I was thinking of, not trying to suggest or imply anything else!!
I think especially in psychiatry it’s easy to provide low quality care . Most psychiatrists are doing 15 minute med checks which I don’t think is enough time to provide proper care . Some patients are so complex they need longer appointments . A lot of psychiatrists just see the patient and hand them a prescription . This has led to tons of issues in our field . Such as Axis II conditions being diagnosed as bipolar , schizophrenia.Also patients with Axis II conditions on a benzo ,stimulant and antipsychotic.
I’m unsure how it’s not malpractice to diagnose someone as bipolar when they actually have BPD. Giving meds to borderlines instead of telling them to go to DBT is extremely bad care .
The other problem like the op mentions is our patient population . A lot of people with eating disorder or Axis II disorders don’t want to change their maladaptive behavior. It’s hard to go to work daily and think you’re trying so hard and none of your pts are improving. My first job out of residency was predominantly working in an IP unit where people had ASPD and were their for HI. It took me a year to burn out and quit .
Now I work in a unit for pts who mostly have depression ,anxiety and sud . Which I enjoy I prefer IP work because I can spend a longer time talking with patients . I also do a lot of family sessions with the social worker . This may seem unusual to some . But I want to help my patients as much as I possibly can .
I would estimate 75% of patients that are referred to me don’t have axis 1 disorders. They are a mix of axis II, self medicating abusive relationships and CD. They have been mismanaged for years by pcps and crappy mental health providers. No wonder there is poor access to psychiatric care. The system is clogged with people who don’t need, wont benefit and will probably just be harmed by medications. No one wants to tell them no including therapists who push them towards meds.
Where are you getting such a poor mix of patients?
I dont think you understand what malpractice is. It is a form of negligence in which there is a deviation from the standard of care that leads to harm. prescribing drugs for patients with BPD is the standard of care. even the APA's own guidelines recommend the use of the same medications used in the treatment of bipolar disorder for the various symptom clusters of BPD. telling patient to go to DBT is not treatment. It's just silly. Telling patients anything, particularly ones who are help-rejecting is doomed to failure. Telling them to get a treatment which may not even be readily available may be seen as more negligent than prescribing drugs for these patients (and the vast majority of patients in this country are not able to access a fidelity DBT skills group). It would be considered extremely rare for patients with BPD to receive no meds at all. even if they engage in DBT they will often be on meds and continue on such meds after treatment. Also remember that 1 in 5 pts with BPD have comorbid bipolar disorder.
I work in a poor, rural area. It seems half my patients are in some way related (not joking) and come from multi-generational dysfunction.
NAMI Honors Dr. Marsha Linehan, The Creator of Dialectical Behavior Therapy | NAMI: National Alliance on Mental Illness
This is what Linehan herself says about medications with BPD. Taper down and off if possible and everybody is over medicated.
No disrespect to Dr Linehan but should be no surprise someone who invented/marketed a treatment is likely to promote said treatment. Not saying it’s bad advice to limit meds to what’s necessary in BPD, but just like you should take a grain of salt with recs from psychiatrists closely tied to pharma you have do the same with those who package psychotherapy concepts.
The evidence base for DBT in BPD is very solid. Medications not so much and lots of harm with antipsychotics, stims, Benzos that are used.
The standard of care for BPD is DBT. I do prescribe meds for people with BPD who also have a co morbid Axis I condition. The only med that I seen evidence for that is effective in bipolar and BPD is lamictal. Anti-psychotics aren't shown to be effective in treating BPD. I live in an area where DBT is widely accessible. So I sometimes forget that DBT isn't widely accessible in some places.
But if we can't just invoke a magical acronym and banish them from our presence, however will we summarily reject them without feeling bad about it?
You must have a pretty functional patient base. I feel like if a good number of my patients miss their meds and appointments they end up on the inpatient unit
Why is it a rejection if you can’t offer appropriate care?
As @splik noted above, pharmacotherapy is not inappropriate in many cases of people with BPD. Similarly, a general psychiatrist operating according to GPM principles can actually do quite well - there is a fair amount of empirical evidence suggesting non-inferiority in comparison to more expensive/involved/specialized therapies. There is a sampling issue in interpreting this literature, as I think the people likely to make it to a high fidelity DBT team, especially in a research setting, are probably not entirely representative of the average person who gets this diagnosis, but it remains the case that seeing the letters "BPD" = "DBT or GTFO".
Now if you are in a setting where you are only going to be seeing someone every three months for 15 minutes at a time, probably yes you want to refer that person on.
Where I practice when BPD is diagnosed is generally not disclosed to the patient and they are put on numerous medications for symptom management. These patients are not abandoned but overtreated.
Unfortunately I am often on the receiving end getting these BPD patients after receiving inadequate care for many years. Psychiatric care only for BPD is substandard and in reinforces Externalization. Too many psychiatrists because of their own narcissism think they can help these patients when they lack the skills and resources.They don’t get better they are on numerous medications that compromise their health and it’s really sad. If you look at the research on BPD the prognosis is not bad much better than other psychiatric disorders with a good chance of recovery If they get good treatment. Another problem is many people equate BPD with patients I don’t like and it’s misdiagnosed. Narcissistic personality disorder and dependent personality disorder are ones I very often see misdiagnosed as BPD.
I mean much of what you are saying is true, especially about diagnostic clarity. That is something you can certainly give all the categories of patients you are talking about. Discuss the prognosis, phenomenology, theories about how it comes about. Emphasize that they should see a therapist but that doesn't mean you're going to abandon them.
Don't overtreat. Talk about how the meds never seem to help for very long and you're going to do something very different together, that you are going to work with the patient to figure out which specific medications are doing what and get to the point where those are the only medications the patient is taking. Explain why benzos are not going to be one of those medications.
Just because you are seeing someone as a psychiatrist does not mean you have to increase the dose or add a medication every time they come into your office.
I've said it before, but lean into the medical model of "BPD is a heritable condition that gets better" and act like it. Be a bit more directive in a positive direction. Don't freak out when they mention feeling suicidal and go into crisis mode if that's not unusual for them.
Read Gunderson, there is nuance to it and experience is really helpful but it is not actually rocket science. The most recent GPM handbook is like 160 pages and half of those are examples. It's probably not going to do the trick for people who are self-harming constantly in a fairly serious way or making a dozen suicide attempts in a year but that is also a tiny minority of people who can be conceptualized as BPD.
My inclination for dealing with NPD and DPD is probably to discuss the phenomenology and impact it is having on their lives without speaking the name of the disorder right away, but I admit it's not my area of expertise and reflects somewhat my dislike for the reification of personality dysfunction as a medical condition. BPD is a little different because supplying a more positive identity can be so salutary.
This is a super important fact that for some reason doesn’t get appreciated by some residents. I have a patient with schizophrenia I see every month or two for “medication management”. The last half year or more patient has not been on any meds because several factors pushed the risk/benefit ratio to favor no meds. That doesn’t stop me from seeing her at same frequency as it is very helpful to the patient/family and insurance has no issue with billing as I’m considering meds at each visit and document the clinical reasoning.