how to become a great psychiatrist?

[psychhunter]

I'm going to be starting residency in psych in a few short months and would love some advice/recommendations on how to become a great psychiatrist.

I understand being good at listening and being empathetic with patients are very important, but are there any concrete things I can work on becoming a great psychiatrist? for current residents and attendings, what are some things that you found to be helpful in your personal/professional growth or has been foundational in your practice in psych? I'm not sure what I am expecting for an answer, but I am definitely planning to go through all the articles recommended by Splik...

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[GEToutLADYits6AM]

What was your step 1 score? did you do any extracurriculars fam? Thanks

 

[Merely]

I'm going to be starting residency in psych in a few short months and would love some advice/recommendations on how to become a great psychiatrist.

I understand being good at listening and being empathetic with patients are very important, but are there any concrete things I can work on becoming a great psychiatrist? for current residents and attendings, what are some things that you found to be helpful in your personal/professional growth or has been foundational in your practice in psych? I'm not sure what I am expecting for an answer, but I am definitely planning to go through all the articles recommended by Splik...

Going through all of spliks articles is going to take you years lol but it’s a worthwhile endeavor

 

[NJWxMan]

Learn how to set reasonable limits with patients, staff, and management.

Find a good mentor early in your training/career.

Develop a strong psychopharmacology background (patients appreciate when you are able to make the correct medication decision the first go around).

Learn how to talk with patients and families.

 

[OldPsychDoc]

Be comfortable in your own skin. Know that the measure of "greatness" is not how much other people like you--patients or faculty.

 

[Sushirolls]

Strive to become the Psychiatrist you would want to see or you would want your own family to see.

 

[birchswing]

Try one of every pill. Taste the rainbow.

 

[Trismegistus4]

Phase 1: Psychiatry residency
Phase 2: ?
Phase 3: Profit

 

[thoffen]

Splik sure is a great wellspring, but I'll be damned if anyone can replicate him. You want to be yourself anyway but the best you. I think, importantly, the best psychiatrist is not likely close to the most acclaimed one. It's hard to deal with doing the right thing and getting no reward or even hostility for it, but it's a position you have to be willing to hold from time to time. Of course, you'll get plenty of reward as well.

For me, individual therapy has been my most valuable ally.

 

[nitemagi]

For me, being a great psychiatrist means becoming a great therapist and a great psychopharmacologist -- ie trying to become the whole package. And becoming a great therapist is a big endeavor and worthy of a much longer conversation, centering on getting solid training in a primary modality and then growing from that foundation into multiple other platforms.

 

[Dharma]

There are a lot of answers to this. My advice (although I'm far from great myself) is to be consistently present with your patients and curious regarding their experience/perspective/pathology etc.

 

[Wilf]

Master psychopharmacology.
Know general medicine fairly well.
Have a natural ability to gain rapport with patients of almost any type and be the type of person who is very tough to fluster.
Have a working knowledge of therapy modalities/psychological testing.

 

[WisNeuro]

You become a great psychiatrist by........CRUSHING YOUR ENEMIES!

 

[dl2dp2]

The field is completely and irreversibly changing IMO. With esketamine and brexanolone newly approved, handful of other injections and depots fancy formulations in various subspecialties, I'd say the first order of business of being a good psychiatrist is being a good general physician, being comfortable with meds, side effects, documentations, collaboratively work with other specialists.

Subfields like perinatal psychiatry/women's mental health used to be EXCLUSIVELY psychotherapy based. Not it's almost EXCLUSIVELY complicated medication subspecialty. As is addiction. And child. Almost all these subspecialties used to be largely therapy based. Any "pathology" that doesn't require medication will no longer be a disorder (i.e. "hysteria", "homosexuality"). Lots of *devices* also in the pipeline. Psychotherapy will also still be there, but even then it's becoming very complicated and technical, all kind of alphabet soup type of specialized therapy. This field is posed to become more and more technical and less and less touchy feely in nature. "Being a good listener" remains important of course as any good doctor can be, but if you want to be forward thinking I would focus more on pharmacology, neuroscience, statistics, healthcare policy and economics, implementation science, etc.

 

[Amygdarya]

Just for the sake of pedantry, "hysteria" is effectively conversion aka functional neurologic disorder. Personality disorders are not going anywhere either.

While I agree that it's important to stay on top of your neuroscience and psychopharm, I believe that psychiatrists should be more adept at establishing therapeutic alliance and understanding patients motivations than any other "well listening" doctor. As has been discussed ad nauseum, this is relevant even if you're doing strict psychopharm. Not to mention the fact that our clinical population is enriched for personality disorders and you better know how to deal with them (something other doctors are not equipped to do as evidenced by consults).
I mean, I'm just an intern but I've seen a good number of patients with "treatment-resistant depression" where a lot is going on personality wise.
A good example of the importance of understanding patient as a person even in a "psychopharm" case is discussed in Chen et al. Harvard Review of Psychiatry. 2018 Jan/Feb; 26 (1): 27-35.

Psychiatry is different from other medical specialties in that things other than individual anatomy and physiology can play a significant role in patient's pathology. Thus I don't think it will - or should - become completely "biological".

 

[nitemagi]

The field is completely and irreversibly changing IMO. With esketamine and brexanolone newly approved, handful of other injections and depots fancy formulations in various subspecialties, I'd say the first order of business of being a good psychiatrist is being a good general physician, being comfortable with meds, side effects, documentations, collaboratively work with other specialists.

Subfields like perinatal psychiatry/women's mental health used to be EXCLUSIVELY psychotherapy based. Not it's almost EXCLUSIVELY complicated medication subspecialty. As is addiction. And child. Almost all these subspecialties used to be largely therapy based. Any "pathology" that doesn't require medication will no longer be a disorder (i.e. "hysteria", "homosexuality"). Lots of *devices* also in the pipeline. Psychotherapy will also still be there, but even then it's becoming very complicated and technical, all kind of alphabet soup type of specialized therapy. This field is posed to become more and more technical and less and less touchy feely in nature. "Being a good listener" remains important of course as any good doctor can be, but if you want to be forward thinking I would focus more on pharmacology, neuroscience, statistics, healthcare policy and economics, implementation science, etc.

Meh. I've been hearing this party line for a decade. IMHO those that trumpet this don't really understand the full range of tools that psychotherapy includes and how effective it can be when done well. Reducing the understanding of psychotherapy to a manualized approach is as reductive as reducing depression to a serotonin problem.

 

[dl2dp2]

Meh. I've been hearing this party line for a decade. IMHO those that trumpet this don't really understand the full range of tools that psychotherapy includes and how effective it can be when done well. Reducing the understanding of psychotherapy to a manualized approach is as reductive as reducing depression to a serotonin problem.

I actually agree with you. But what I’m seeing in the community is that practicing psychiatrists are going where the money is. Except in certain segments (outpatient cash) MDs are focusing on these flashy new toys of questionable efficacy—make no mistake some do work very well, but others don’t—that make the most money for everyone. The main players here are actually *big hospitals* and *big practice groups*. They can advocate for higher billing for high tech toys and more intensive, regulated sub specialty visits. So I’m just directing the trainees to recognize this. It’s just inevitable that all of medicine is going in this direction...it’s like how in neurology the role of a old school neurological exam is getting smaller and smaller mostly because of billing etc. it’s extremely difficult to argue against managed care that you can deliver therapy better than another provider who’s half cheaper and in market oversupply. Wealthy patients of course prefer integrated care, but insurance just won’t touch it.

I am often mystified why DBT gets no public or private funding. But this is clearly a losing battle.

 

[deleted736562]

I think what the separates the "great" from the rest is the ability to listen in an empathetic manner, known your personal baggage/countertransferance issues, develop rapport and interview therapeutically. Work on recognizing your inner gut sense and what it means (much of the work is here, and not cognitive) but also make sure to sit back sometimes and hone your observational skills. I feel like that's the solid basis we should strive for, and therapy training has actually been much more useful for these goals than neuroscience/pharmaco. So if I have concrete advice, get more intensive therapy training if your program is short on that.

It's important to know the basics of pharmaco, but a lot of the "nerdier" stuff in Stahl or whatever isn't really that useful. Same applies to neuroscience. Good to have literacy but so far it's still not all that relevant. I would say what's important however is to really dig into the primary literature, know the state of the evidence for treatment options and how to properly appraise it. Saying all of this as a more neuro research type of person.

 

[mojetter]

I actually agree with you. But what I’m seeing in the community is that practicing psychiatrists are going where the money is. Except in certain segments (outpatient cash) MDs are focusing on these flashy new toys of questionable efficacy—make no mistake some do work very well, but others don’t—that make the most money for everyone. The main players here are actually *big hospitals* and *big practice groups*. They can advocate for higher billing for high tech toys and more intensive, regulated sub specialty visits. So I’m just directing the trainees to recognize this. It’s just inevitable that all of medicine is going in this direction...it’s like how in neurology the role of a old school neurological exam is getting smaller and smaller mostly because of billing etc. it’s extremely difficult to argue against managed care that you can deliver therapy better than another provider who’s half cheaper and in market oversupply. Wealthy patients of course prefer integrated care, but insurance just won’t touch it.

I am often mystified why DBT gets no public or private funding. But this is clearly a losing battle.

I absolutely agree with you..at least here in South Florida patients are VERY receptive to things like TMS, Ketamine, Genetic Swab Testing, Infusions, B12 Shots, Long Acting Naltrexone, etc, etc.

...and the patients ask about new developments all the time, you have to have an answer for them besides "well we dont know the whole story about that treatment yet."

Admittedly this population has lots of education, money, people relocating here from all over the US and world, and is the substance abuse/rehab capital of the US if not the world. Its much less of an academic cerebral approach than I was trained in.

A private pay practice can easily be lucrative if the right doctor has these tools at their disposal.

 

[clausewitz2]

I actually agree with you. But what I’m seeing in the community is that practicing psychiatrists are going where the money is. Except in certain segments (outpatient cash) MDs are focusing on these flashy new toys of questionable efficacy—make no mistake some do work very well, but others don’t—that make the most money for everyone. The main players here are actually *big hospitals* and *big practice groups*. They can advocate for higher billing for high tech toys and more intensive, regulated sub specialty visits. So I’m just directing the trainees to recognize this. It’s just inevitable that all of medicine is going in this direction...it’s like how in neurology the role of a old school neurological exam is getting smaller and smaller mostly because of billing etc. it’s extremely difficult to argue against managed care that you can deliver therapy better than another provider who’s half cheaper and in market oversupply. Wealthy patients of course prefer integrated care, but insurance just won’t touch it.

I am often mystified why DBT gets no public or private funding. But this is clearly a losing battle.

If the flashy new toys are of questionable efficacy, don't you think insurers are going to push back against it at some point?

There is a billing code for narcosynthesis and was the height of psychiatric technology at one time, but I think you would find it very hard today to find an insurer who would pay for it.

EDIT: also re your earlier point about increasingly specialized alphabet soup therapies, I think there is a huge push now for transdiagnostic approaches addressing common elements of mental health instead of highly specific, narrow protocols. So therapy may be moving in the opposite direction to what you are describing.

 

[Liquid8]

If the flashy new toys are of questionable efficacy, don't you think insurers are going to push back against it at some point?

It also raises an ethical question - should one even be offering treatments of questionable efficacy to patients if known effective alternatives exist?

To the OP, I don’t know how to really define “Great” when it comes to psychiatrists. But to be "good enough", I would suggest trying to be kind, curious and non-judgemental.

I think being knowledgeable about our treatment options, both biological and psychological is a given and an absolute bare minimum, even if one elects not to utilise a certain area. While my area of expertise is in medication management, I always enquire as to exactly what kind of therapy patients may be doing with others, as sometimes it may not be the most appropriate for their particular issues. On the other end of the treatment scale while I don't perform ECT, I will prescribe it to patients where it is clearly indicated so I need to know enough to get their consent which involves allaying their fears and being able to answer any questions raised.

 

[clausewitz2]

It also raises an ethical question - should one even be offering treatments of questionable efficacy to patients if known effective alternatives exist?

To the OP, I don’t know how to really define “Great” when it comes to psychiatrists. But to be "good enough", I would suggest trying to be kind, curious and non-judgemental.

I think being knowledgeable about our treatment options, both biological and psychological is a given and an absolute bare minimum, even if one elects not to utilise a certain area. While my area of expertise is in medication management, I always enquire as to exactly what kind of therapy patients may be doing with others, as sometimes it may not be the most appropriate for their particular issues. On the other end of the treatment scale while I don't perform ECT, I will prescribe it to patients where it is clearly indicated so I need to know enough to get their consent which involves allaying their fears and being able to answer any questions raised.

I did not bother with the ethical question because I have engaged with him/her before on questions like this and was told that ethics were a luxury for rich white people if there was money to be made, so I figured it was not worth it. For the record I think the answer is definitely no in the absence of compelling reasons why the effective alternatives are impossible in a particular case.

 

[dl2dp2]

If the flashy new toys are of questionable efficacy, don't you think insurers are going to push back against it at some point?

There is a billing code for narcosynthesis and was the height of psychiatric technology at one time, but I think you would find it very hard today to find an insurer who would pay for it.

EDIT: also re your earlier point about increasingly specialized alphabet soup therapies, I think there is a huge push now for transdiagnostic approaches addressing common elements of mental health instead of highly specific, narrow protocols. So therapy may be moving in the opposite direction to what you are describing.

Oh I think they will. TMS will be gone before you know it. But the whole point of science is that old toys will be replaced with new toys, which will be more and more expensive to play with, and eventually one of them will work well. A bigger and existent push is insurance will not want MDs to deliver psychotherapy. It’s really a change or die kind of a thing. LCSWs can easily do therapy. And if you want to do cash it’s not the MD people care about it’s where you did your MD. Lots of old school analysts are converting back to psychopharmacology practices—I see it with my ow eyes! Analytic institutes are literally declaring bankruptcy. There is a lack of demand. You can bemoan the sad loss thereof or you can try to adapt.

I did not bother with the ethical question because I have engaged with him/her before on questions like this and was told that ethics were a luxury for rich white people if there was money to be made...

Same answer. Exactly right! I only care about what’s written down. (Someone elses’) ethics is meaningless to me until it becomes a consensus guideline. It’s just too hard to tell what is ethics and what is hubris, especially when money is involved. Secondarily, for the kind of indications we are talking about (TRD) there aren’t much in terms of effective existing treatments. I personally don’t peddle what I think as ineffective treatments, but it’s not because I have some ethical qualm with people who do in order to make more money. It’s just my stylistic choice—there’s an “elegance” to a well designed and minimal psychopharm regimen that’s effective.

 

[MacDonaldTriad]

For five or six decades everyone has been saying we are on the verge of a revolutionizing breakthrough in psychiatry. Show me a marketed antipsychotic that doesn't block D2 and maybe I'll believe this. There are a couple of examples of antidepressants that don't block reuptake of a monoamine, but they are hardly taking over. Anxiolytics manipulate the Gaba/Glycine ratio but nothing much different than when the first piece of old fruit fermented. Pardon my pessimism, but nothing has changed that much in my lifetime.

 

[Monocles]

Gonna add something that hasn't been mentioned thus far...

Self care! If you're burned out, miserable, depressed, then you're going to be less effective than if you were not. Always do what you can to take care of yourself mentally as you are taking care of others. 🙂

 

[Sushirolls]

TMS will be gone before you know it.

Disagree. It will expand. The paradigm to emerge, in my opinion is simple. 2 or 3 failed trials of meds and/or therapy ("treatment resistant depression) = Neurostimulation consult.

Neurostimulation consultant has discussion of pros/cons of TMS vs ECT.

Remission rates of meds for 3rd trial = ~15%
Remission rates for TMS= ~35%
Remission rates for ECT= ~65%

TMS isn't going anywhere, nor is it a gimic. And with a new publication reflecting 2-3min treatments duration that yield remission in 4-5 days, it will likely need to be in every psychiatric practice. The old 20-40min treatments will start to go out the window.

 

[splik]

There is a billing code for narcosynthesis and was the height of psychiatric technology at one time, but I think you would find it very hard today to find an insurer who would pay for it.

medicare and many commercial PPO insurances do reimburse for this. HMO plans often don't cover it or require prior authorization. It is very rarely used, but it does still have its place 😉

 

[Merely]

Disagree. It will expand. The paradigm to emerge, in my opinion is simple. 2 or 3 failed trials of meds and/or therapy ("treatment resistant depression) = Neurostimulation consult.

Neurostimulation consultant has discussion of pros/cons of TMS vs ECT.

Remission rates of meds for 3rd trial = ~15%
Remission rates for TMS= ~35%
Remission rates for ECT= ~65%

TMS isn't going anywhere, nor is it a gimic. And with a new publication reflecting 2-3min treatments duration that yield remission in 4-5 days, it will likely need to be in every psychiatric practice. The old 20-40min treatments will start to go out the window.

2-3min duration sounds like an insane money maker,right?

 

[Mindfulpsych22]

As a psychologist, here are some things that I have appreciated or perceived to separate a great psychiatrist from the average:

1) high degree of collaboration with collateral and other providers. You would be surprised the lengths I and patients have had to go to merely get a psychiatrist to return phone calls to me or other ancillary providers. I work with a complex and high-risk population and close team work and collaboration tends to be hugely important but very difficult to get.

2) do thorough diagnostic assessments. Do not just tell/explain a diagnosis to a patient, but also take the time to do some psychoed on our diagnostic SYSTEM and the pros and cons of the way we diagnose mental disorders. This really help patients know how interact in an effective way with the concept/label of what is going on with them (choosing Tx likely to help them, understanding prognosis, etc) while avoiding some of the misconceptions about diagnostic labels that lead to entrenchment of dysfunction or worsen functioning.

3) have a solid understanding of the treatments that you are referring patients to. We get many referrals for a specific type of therapy we provide from psychiatrists that don’t know a lot about it, and thus don’t really know the details of what they are recommending, which leads to problems. This helps everyone be on the same page from the start, and helps with patient buy-in.

4) ask patients for feedback! Be friendly and validating, non-defensive when patients do speak up. I commonly have to work with patients on being assertive with psychiatrists because many find you very intimidating 😉 (I think a combination of the MD, sometimes less choice in choosing a psychiatrist due to shortages that lead to less of a good “fit,” less frequent visits than therapy so not as much time together). Coming across that you will hear someone out and validate them even if you disagree really helps them take that step to speak up and continue to do so.

 

[clausewitz2]

As a psychologist, here are some things that I have appreciated or perceived to separate a great psychiatrist from the average:

1) high degree of collaboration with collateral and other providers. You would be surprised the lengths I and patients have had to go to merely get a psychiatrist to return phone calls to me or other ancillary providers. I work with a complex and high-risk population and close team work and collaboration tends to be hugely important but very difficult to get.

2) do thorough diagnostic assessments. Do not just tell/explain a diagnosis to a patient, but also take the time to do some psychoed on our diagnostic SYSTEM and the pros and cons of the way we diagnose mental disorders. This really help patients know how interact in an effective way with the concept/label of what is going on with them (choosing Tx likely to help them, understanding prognosis, etc) while avoiding some of the misconceptions about diagnostic labels that lead to entrenchment of dysfunction or worsen functioning.

3) have a solid understanding of the treatments that you are referring patients to. We get many referrals for a specific type of therapy we provide from psychiatrists that don’t know a lot about it, and thus don’t really know the details of what they are recommending, which leads to problems. This helps everyone be on the same page from the start, and helps with patient buy-in.

4) ask patients for feedback! Be friendly and validating, non-defensive when patients do speak up. I commonly have to work with patients on being assertive with psychiatrists because many find you very intimidating 😉 (I think a combination of the MD, sometimes less choice in choosing a psychiatrist due to shortages that lead to less of a good “fit,” less frequent visits than therapy so not as much time together). Coming across that you will hear someone out and validate them even if you disagree really helps them take that step to speak up and continue to do so.

Lord yes about psychiatrists needing to understand what they are referring people for. "Go do DBT" isn't a great suggestion if someone isn't prepared to spend a year of their life meeting a team a couple times a week. "Oh you need ERP/trauma-focused and also we are going to ask you to deliberately experience that thing you structure your life around avoiding over and over again" would probably lead to a lot fewer dropouts after intake on y'all's end.

 

[TexasPhysician]

2-3min duration sounds like an insane money maker,right?

Building a practice large enough to have that many TRD patients is incredibly difficult. You’ll essentially need to spend a ton on marketing to draw them in.

 

[Stagg737]

Get into residency, learn the basics/build a foundation of knowledge, see as much as you can, find what you're passionate about and/or interested in and then master that. The last step doesn't necessarily mean sub-specializing. It can mean working with rural/underserved patients or specific populations, being good at stabilizing acute crises, focusing on specific disorders or symptoms/behaviors, or mastering specific treatment modalities.

There isn't going to be a set definition of "greatness" and it will be up to you to earn that recognition. I think the only pre-requisites for this are developing a strong foundation of knowledge and learning to recognize when something is outside of what you can treat and how to refer that patient properly. Beyond that it is simply working hard and continuing to learn and grow throughout your career. How one choose to do that is up to them.

 

[FlowRate]

2-3min duration sounds like an insane money maker,right?

Until it gets nerfed by CMS. But the interval time will certainly be lucrative, should you be able to fill.