How to include more medicine in your psychiatry career

[yanks26dmb]

Working my way through intern year and realizing I really do enjoy the medicine side of things as well. Any ways to increase medicine exposure with a career in psychiatry?

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[FlowRate]

Doing CL will give you medicine exposure but honestly it's a far cry from actually practicing internal medicine IMO. In that regard, inpatient psych where you manage your patients' simple medical issues is actually a better fit.

 

[TexasPhysician]

Inpatient psych, residential addictions, and pp outpatient will allow you to do as much medicine as you would ever want.

 

[dl2dp2]

Addiction is a fairly medicalized specialty. A lot of IM people go into addiction medicine.

In day to day practice, I would say most of the psychiatry is very heavily medicalized. Or do you mean you want to adjust people's blood pressure meds for a living?

 

[Bartelby]

I agree with the inpatient recommendation above. Lots of acute and relatively undifferentiated patients, which means sharper medical skills are important.

 

[wolfvgang22]

Geriatric psychiatry, especially inpatient affords a lot of opportunities to be more involved in the medicine aspect of patient management. I do some consulting to a nursing facility. It takes forever and you can spend hours sifting through polypharmacy, and puzzling through competing cardiac, metabolic, renal, and neurological conditions impacting your patients mental status. After the fun of the challenge wears off you will recall why you didn't match into IM.

 

[Evidence Based]

Depends what you mean by "medicine." If you like thinking through medically complex patients and how organ system dysfunction affects or produces psychiatric problems, then C/L could be a good fit (and a ton of fun). But as others have pointed out, you do almost no medical management of these problems.

If what you really want is to be managing someone's BP meds, insulin, or treating other chronic medical conditions, then inpatient psych (especially Geri) could be a good fit for you. I personally find that stuff quite boring, which is why I'm in psychiatry!

Emergency Psych could also be a good fit, as patients as the most undifferentiated and busy EDs will often miss medical contributions in their "medical clearances" and try to turf medically ill people to psych before they're ready. In this case, you're be diagnosing/recognizing these problems, but not managing them.

I'm just a PGY-2, but ideally we should all be using our medicine brains with all our patients in all settings, but the way we do it will obviously vary.

 

[Shufflin]

I'm the primary for detox patients, not the consulting psychiatrist, but the primary doctor. Yesterday I had to calculate how much Lantus and NPH to give and what schedule sliding scale to use. Another patient has venous stasis ulcers. Had to start wet to dry wound care, get a culture, and order antibiotics. Another has untreated HTN. So I'm starting antihypertensives for that patient.

Point is, you can find a job in a detox unit as the primary. I have fellowship training that was medicine heavy, so I'm in my comfort zone. Most psychiatrists would run far and fast from this kind of stuff. You seem interested however. You'll need fellowship training.

 

[reca]

I'm the primary for detox patients, not the consulting psychiatrist, but the primary doctor. Yesterday I had to calculate how much Lantus and NPH to give and what schedule sliding scale to use. Another patient has venous stasis ulcers. Had to start wet to dry wound care, get a culture, and order antibiotics. Another has untreated HTN. So I'm starting antihypertensives for that patient.

Point is, you can find a job in a detox unit as the primary. I have fellowship training that was medicine heavy, so I'm in my comfort zone. Most psychiatrists would run far and fast from this kind of stuff. You seem interested however. You'll need fellowship training.

What fellowship?

 

[Shufflin]

What fellowship?

I sent you a PM

 

[nowaysanjose]

Doing CL will give you medicine exposure but honestly it's a far cry from actually practicing internal medicine IMO. In that regard, inpatient psych where you manage your patients' simple medical issues is actually a better fit.

It seems like all these positions have NPs who manage these issues?

 

[Fabio001]

I have to wonder if what you're moreso saying is, "I'm the kinda person who tends to like what I'm doing", and it just so happens that right now in your internship, general medicine is how a lot of your time's spent. I know that's how I was all though medical school and internship too.

My advice would be that, if you find yourself missing medicine one year from now, come back and ask your question again. In my experience, most folks in psychiatry have few regrets about permanently leaving behind complex insulin management, antihypertensives, and antibiotic algorithms. I think there was one person in my residency class who maintained that attitude throughout, even though the rest of us started out there with her.

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[TexasPhysician]

It seems like all these positions have NPs who manage these issues?

At inpatient psych, residential addictions, and pp, the psychiatrist is the primary physician. No other physician or midlevel follows patients regularly in my experience. This gives the psychiatrist first dibs at treating anything and everything. The psychiatrist also can consult or refer to medical staff. It becomes your choice as to how involved medically that you want to be.

 

[NITRAS]

At inpatient psych, residential addictions, and pp, the psychiatrist is the primary physician. No other physician or midlevel follows patients regularly in my experience. This gives the psychiatrist first dibs at treating anything and everything. The psychiatrist also can consult or refer to medical staff. It becomes your choice as to how involved medically that you want to be.

Not entirely true. At some point you’ll make your staff/fellow physicians uncomfortable if you are much more medically involved than your peers.

 

[downwithDTB]

Not entirely true. At some point you’ll make your staff/fellow physicians uncomfortable if you are much more medically involved than your peers.

Unless you're talking about doing gyn exams on every patient who is behind on their pap smears, I'm not quite sure I understand...

The attending physician of a given patient is responsible for their treatment, period. If you're delegating a portion (e.g. "medicine") to someone else, you're still completely responsible for their choices. Anyone who blindly delegates the medicine of their patients to someone (especially someone with significantly less internal medicine training than themselves (i.e. an NP or PA)) and is taking big risks and doing their patients a disservice.

Using a mid-level as an extender and personally verifying all positive and negative findings and approving the treatment plan is one thing (which allows you to be directly involved in the medicine), while blindly delegating is another. Outpatient, you can refer someone to a PCP, but inpatient, they are simply consultants to you and if you can't personally manage (with consultation) then it's your duty to transfer to someone who can.

....which brings me to the point of: if a hospital has hired NPs to run the "medicine," if I were the psychiatrists I would get together and ask the boss to fire the NPs and divide up the 80% of the salary savings between the psychiatists and let them keep the rest...

 

[FlowRate]

At inpatient psych, residential addictions, and pp, the psychiatrist is the primary physician. No other physician or midlevel follows patients regularly in my experience. This gives the psychiatrist first dibs at treating anything and everything. The psychiatrist also can consult or refer to medical staff. It becomes your choice as to how involved medically that you want to be.

I have heard that it's common outside of academics to have either a rotating IM/FP or an NP managing the medical issues.

 

[MBBSMOM]

I have heard that it's common outside of academics to have either a rotating IM/FP or an NP managing the medical issues.

I've worked at many community psychiatric hospitals we usually have IM sometimes NP managing the medical issues. They are not the primary attending though they act mostly as consultants. They do the initial physical exam and then monitor ongoing medical issues during the inpatient stay.

 

[SourceOfDenial]

Consider palliative care. Example of major interventions over the course of a day: trauma focused psychotherapy, reductions of BP meds to manage hypotension and falls, opioids and breathing exercises for breathlessness, ketamine infusion for depression/pain, and a smattering or goals of care.

 

[TexasPhysician]

I have heard that it's common outside of academics to have either a rotating IM/FP or an NP managing the medical issues.

I’ve never worked anywhere in which a NP/IM/FP or whatever simultaneously rounds on all patients to manage issues. They are generally there when I consult them only.

 

[nowaysanjose]

I've worked at many community psychiatric hospitals we usually have IM sometimes NP managing the medical issues. They are not the primary attending though they act mostly as consultants. They do the initial physical exam and then monitor ongoing medical issues during the inpatient stay.

I really dislike this. How are we supposed to use the argument that our medical training is what makes us so different from psychologists attempting to prescribe if we don’t even use said training?

 

[clausewitz2]

I’ve never worked anywhere in which a NP/IM/FP or whatever simultaneously rounds on all patients to manage issues. They are generally there when I consult them only.

Our place has a small army of PAs but mostly consultants. The exceptions are the geriatric and child floors, for which each patient is followed by the family medicine service with an FM attending following the trickiest cases directly. We get some pretty medically I'll people, I would not want a psychiatrist taking sole responsibility for managing them.

 

[FlowRate]

I really dislike this. How are we supposed to use the argument that our medical training is what makes us so different from psychologists attempting to prescribe if we don’t even use said training?

We do use said training. We prescribe medications which have medical adverse effects. Some require lab, vitals, or physical symptom monitoring.

 

[MBBSMOM]

We do use said training. We prescribe medications which have medical adverse effects. Some require lab, vitals, or physical symptom monitoring.

Exactly what I was going to say we use our medical training to prescribe. It takes medical knowledge to prescribe to pregnant pts, medically ill pts or using meds like lithium and clozaril. Psych NPs at best anyway only have 2-3 required classes in assessment and pathophysiology. Which is not any better and yet they are allowed to prescribe all psych meds. If I could I would change the laws to only allow non-physician prescribers to be able to prescribe SSRIS to healthy pts.

 

[downwithDTB]

Our place has a small army of PAs but mostly consultants. The exceptions are the geriatric and child floors, for which each patient is followed by the family medicine service with an FM attending following the trickiest cases directly. We get some pretty medically I'll people, I would not want a psychiatrist taking sole responsibility for managing them.

I have far more training in internal medicine and pediatrics than an NP or PA and have extensive experience doing physical exams and diagnoses on psychotic patients under close supervision... passed medical licensing exams... how is it that a PA (or NP) is more qualified than a psychiatist to practice any branch of medicine? Personally, I'd take a psychiatrist as my primary provider over a PA/NP any day of the week...

 

[SourceOfDenial]

You all must work with some crappy NPs/PAs, or must be on some high horses. I can count more NPs that I’d trust with the care of a family member than those I wouldn’t want near them.

 

[clausewitz2]

I have far more training in internal medicine and pediatrics than an NP or PA and have extensive experience doing physical exams and diagnoses on psychotic patients under close supervision... passed medical licensing exams... how is it that a PA (or NP) is more qualified than a psychiatist to practice any branch of medicine? Personally, I'd take a psychiatrist as my primary provider over a PA/NP any day of the week...

The calculus is different for residents and people close to their medical training, but when you compare a PA who has been working for a decade doing just IM all day every day versus a psychiatrist who hasn't done anything beyond continue someone's home meds for a decade and who sure as heck hasn't kept up with chronic medical disease management?

How many of your attendings do you reckon are really going to do an adequate job taking care of someone getting dialysis? Or post-op care for someone who shot themselves in the face? Even worse, even if they put in the time to get up to speed with the literature, how many fewer patients are they going to be able to see because they are spending so much time on this?

Most specialists recognize what is and is not is in their wheelhouse, to insist we should be otherwise is bravado. Simple stuff, sure, but that's not what I'm talking about.

 

[TexasPhysician]

You all must work with some crappy NPs/PAs, or must be on some high horses. I can count more NPs that I’d trust with the care of a family member than those I wouldn’t want near them.

I can’t. A NP degree can be done online now.

 

[FlowRate]

I can’t. A NP degree can be done online now.

This is why, as a blanket statement, I trust PA's far more than I trust NP's. PA's basically do a short-form medical school. NP's take online business courses. There's no comparison. Yet NP's are "nurses" and get to decide amongst themselves that they can play doctor without supervision (in some states.)

 

[superfrogpoke]

I sent you a PM

Could you PM me with the fellowship as well?

 

[yanks26dmb]

I have to wonder if what you're moreso saying is, "I'm the kinda person who tends to like what I'm doing", and it just so happens that right now in your internship, general medicine is how a lot of your time's spent. I know that's how I was all though medical school and internship too.

My advice would be that, if you find yourself missing medicine one year from now, come back and ask your question again. In my experience, most folks in psychiatry have few regrets about permanently leaving behind complex insulin management, antihypertensives, and antibiotic algorithms. I think there was one person in my residency class who maintained that attitude throughout, even though the rest of us started out there with her.

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On medicine wards right now. Do not miss medicine. Will be happy doing psych and medicine on a limited as needed basis moving forward. Problem averted.

 

[SourceOfDenial]

On medicine wards right now. Do not miss medicine. Will be happy doing psych and medicine on a limited as needed basis moving forward. Problem averted.

Ha! It’s made all the more challenging being on wards for only a month or two when your co interns on the service have been doing it nonstop since July. Steep learning curve. I remember being told to go manage a heparin gtt within 4 hours of starting wards, and first having to look up what gtt meant.

 

[Daedra22]

Mentioned briefly above, but I second the suggestion that ER psych will keep you on your medical toes. I have seen an incredible breadth of people with serious (some of them ended up in the ICU) medical problems who somehow ended up in triage at the psych ER. I didn't end up managing these cases as I would if I was an IM doc on a medical floor, of course, but I am grateful for my background in general medicine which allowed me to recognize these things when they appeared and get the patients to the appropriate places. It's kind of cool to be able to clearly see when your interventions keep someone alive, when so often in psychiatry what we do is subtle and we don't always know when we've prevented a death. That said, these are stressful situations and I'm always happy when a night goes by without something ridiculous going down. 🙂

 

[clausewitz2]

Mentioned briefly above, but I second the suggestion that ER psych will keep you on your medical toes. I have seen an incredible breadth of people with serious (some of them ended up in the ICU) medical problems who somehow ended up in triage at the psych ER. I didn't end up managing these cases as I would if I was an IM doc on a medical floor, of course, but I am grateful for my background in general medicine which allowed me to recognize these things when they appeared and get the patients to the appropriate places. It's kind of cool to be able to clearly see when your interventions keep someone alive, when so often in psychiatry what we do is subtle and we don't always know when we've prevented a death. That said, these are stressful situations and I'm always happy when a night goes by without something ridiculous going down. 🙂

It sure does come in handy sometimes. I remember one fifty year old lady who kept getting treated ineffectually for depression whose main complaint was fatigue and low energy/motivation. Turns out she also got winded walking the thirty feet from the elevator to my office. Bilateral leg edema, ahree pillow orthopnea and a talk about risk factors and it turns out CHF explains waaaay more of what is going on.

Sent her along for medical evaluation. Not sure what happened after that but she never came back to our clinic in any event.

 

[downwithDTB]

It sure does come in handy sometimes. I remember one fifty year old lady who kept getting treated ineffectually for depression whose main complaint was fatigue and low energy/motivation. Turns out she also got winded walking the thirty feet from the elevator to my office. Bilateral leg edema, ahree pillow orthopnea and a talk about risk factors and it turns out CHF explains waaaay more of what is going on.

Sent her along for medical evaluation. Not sure what happened after that but she never came back to our clinic in any event.

Yeah, she went next door, wrote you a bad review on Yelp, and got some Xanax for her panic attacks with SOB, Ambien to help her fall asleep, Ritalin for energy, Dilaudid for her chest pain and esketamine for her TRD.

 

[clausewitz2]

Yeah, she went next door, wrote you a bad review on Yelp, and got some Xanax for her panic attacks with SOB, Ambien to help her fall asleep, Ritalin for energy, Dilaudid for her chest pain and esketamine for her TRD.

I think this particular lady was not high functioning enough to maximize the fun times pharmacoepia but your point is well taken.

 

[Tapepsi]

It’s exciting when you find something that really interests you! I would suggest to always keep an open-mind throughout your residency. At least for my residency program the first year had so many non-psych rotations it was difficult to really get a good sense of what all the field offers.
My intern year I really thought C/L was what I wanted. Now Im the lead doc of an ACT program and do some outpatient clinic. Complete opposite from where I thought I’d end up but have never been happier and couldn’t imagine doing anything else. Lol

 

[psyguru]

Occasionally I will run into a forensic psychiatry expert witness case that involves medicine. Many times the attorney will not want to hire another expert. One example was a defendant with incompetency to stand trial due to delirium secondary to hepatic encephalopathy. I opined he will not regain competency in the forseeable future as he is not a candidate for liver transplant due to obesity, diabetes, etc. Interesting thing is both the psychologist and the other forensic psychiatrist called it neurocognitive disorder (which is possible but I feel should only be diagnosed in the persistent absence of elevated LFTs)...long term hepatic encephalopathy can potentially lead to neurocognitive disorder.