How to keep up with "Medical" knowledge as a Psychiatrist?

[MrJiggles]

I'm an MS4 and I'm nearly set on applying to Psych residencies, but I do in earnest worry that I would lose a lot of my basic "medical" knowledge in pursuing this career. I feel like the Psych and CL-Psych attendings I work with are superbly knowledgeable in both internal medicine and psychiatry, indeed they seem to see it all as part of the same continuum.

I would like to emulate this, however many of the residents, and many psychiatrists I've met outside of this academic, hospital setting seem to have lost a lot of this knowledge. So how do you guys keep up with it all? I would love to pick your brains.

I'm actually contemplating Med-Psych or Triple-Board programs due to this very insecurity. Or maybe CL-psych, or Onco-Psych, way in the future...

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[nitemagi]

It's tough to keep up on Everything.

Use your time effectively. When you sign up for APA and/or AMA membership you'll get a lot of journals. I actually prefer electronic means -- sign up for electronic table of contents for journals you want to follow -- (http://highwire.stanford.edu/personalize/), for example. Then reach the articles that interest you. I read the basics (annals int med, nejm, etc).

Another thing to try is listening to podcasts/audio CME's, though recognize a lot of those are directly (or covertly) pharma funded so they can be biased that way.

 

[splik]

it's not your basic medical knowledge or the principles of diagnosis and management you lose, its your working knowledge. I know a helluva lot less medicine than I did a year ago, but i know how to recognize a sick patient, what labs to order on my patients, how to tinker about with diuretics, or thyroxine. this week alone i have picked up and treated asymptomatic bacturia in a pregnant patient, written up a bag of fluids on a catatonic patient with starvation ketosis and dehydration (we give IVFs on our psych ward), drawn blood to check the renal function of a crabby psychotic patient on +++nephrotoxic drugs who won't let the phlebotomists do it, I have rx alpha-1 blockers for urinary hesitancy, optimized the analgesia for one of my patients with a broken face as per WHO analgesic ladder, screened for HIV in my african first episode psychosis pt, rx clotrimazole for thrush (did not look at it myself though!), and treated psoriasis in a pt whose skin has started scaling off due to lithiumization....

I have done all this because:
1. i'm bored
2. i am more confident with medicine than with psychiatry
3. i am at a place where the psychiatry dept is quite strong on medicine
4. my attendings are confident with this

i would not waste my time with med/psych as you will get shortchanged on your psych training and on psychotherapy (the difficult bit of psychiatry training). they are dying out because there isn't really a need for them. i dont know about triple board but find it hard to believe you would as well trained a kiddie psychiatrist as if you did 5 years psychiatry. you obviously would get hardly any psychotherapy training at all.

you should ask yourself why have this insecurity? because you don't think you will be a real doctor? Well you won't! (At least in the eyes of the public) - last week a pt asked me if i was a doctor or a psychiatrist! well guess what, orthopaedic surgeons are't 'real doctors' either and they don't care!

and the more i think about it there is a reason i switched to psych - heart failure, psoriasis, UTIs, pneumonia etc are BORING! but you can have endless hours of amusement with acutely manic patients, psychotic patients, or seeing catatonic patients spring back to into action with a bit or lorazapam. and I get to take my patients for ice cream! (the American Diabetic Association diet with an olanzapine chaser)....

 

[notdeadyet]

Every doctor loses the skills not included in his specialty. The trick is picking the specialty that contains the specific skills you dont want to lose.

I'm actually contemplating Med-Psych or Triple-Board programs due to this very insecurity. Or maybe CL-psych, or Onco-Psych, way in the future...

If you're interested in being a psychiatrist in a hospital setting consulting other services, C/L fellowship is the way to go. Doing a combined program, any of which will eliminate elective time and psychotherapy time as splik notes, is a bad compensation for insecurity. Hit it head on. Many folks go through a lot of navel gazing before accepting that becoming a physician specializing in mental illness means some (but not all) of your physical medicine skills will atrophy.

Surgeons don't know $hit about rashes and watch an internist try to do a pap or a squirming ankle biters ear exam. You lose what you don't use but the alternative is to not get really good at something specific.

 

[MrJiggles]

Thanks nitemagi, splik, and notdeadyet. I suppose I agree, if my main goal is being a Psychiatrist, then I should focus on being great at that and go through training that affords me training in all aspects of psych such as psychotherapy as splik said. Admittedly, I do not know how the combined programs would actually even help me career, I don't really want to practice as an Internist or a Pediatrician, I simply want the breath of knowledge spans both physical and mental illness, making me a huge gunner...or a future CL Psych?

And you're right, every specialty loses some general medicine. On a side note, as I have an interest in CL-Psych, do any of you know if there is a "Fast-Track" in CL the way it is for Child/Adolescent? As in, could I start a CL fellowship in lieu of my 4th year of residency? Furthermore, how do I gauge (later, during interviews and such), which psych programs have strong medical training? Would a strong CL dept/influence be a good litmus test in deciding a well rounded and medically apt psych residency?

Sorry about all the questions!

Every doctor loses the skills not included in his specialty. The trick is picking the specialty that contains the specific skills you dont want to lose.

If you're interested in being a psychiatrist in a hospital setting consulting other services, C/L fellowship is the way to go. Doing a combined program, any of which will eliminate elective time and psychotherapy time as splik notes, is a bad compensation for insecurity. Hit it head on. Many folks go through a lot of navel gazing before accepting that becoming a physician specializing in mental illness means some (but not all) of your physical medicine skills will atrophy.

Surgeons don't know $hit about rashes and watch an internist try to do a pap or a squirming ankle biters ear exam. You lose what you don't use but the alternative is to not get really good at something specific.

 

[OldPsychDoc]

..On a side note, as I have an interest in CL-Psych, do any of you know if there is a "Fast-Track" in CL the way it is for Child/Adolescent? As in, could I start a CL fellowship in lieu of my 4th year of residency?

No. In fact, it's basically verboten to apply any of PGY4 to any of the 1 year fellowships--addiction, gero, psychosomatic. Don't even try. It makes your PD sad. And he already has enough problems with the ACGME.

 

[MrJiggles]

Ah I see. Is the "fast track" in C/A Psych an unofficial thing then? Why is the 2 year fellowship different? Also, if say someone hypothetically wanted to do CL psych in a children's hospital, would they have to do a CL fellowship after a C/A fellowship?

No. In fact, it's basically verboten to apply any of PGY4 to any of the 1 year fellowships--addiction, gero, psychosomatic. Don't even try. It makes your PD sad. And he already has enough problems with the ACGME.

 

[OldPsychDoc]

Ah I see. Is the "fast track" in C/A Psych an unofficial thing then? Why is the 2 year fellowship different? Also, if say someone hypothetically wanted to do CL psych in a children's hospital, would they have to do a CL fellowship after a C/A fellowship?

No-- fast-track C/A is official--you actually become board-eligible as an adult psychiatrist after the first (PGY4) year.

 

[BobA]

If length of training is your concern, you can skip the fellowship alltogether and still be able to do consults. This will be especially true if you go to a program with strong CL (quarternary referral center). 4th year is entirely elective most places and you could do a lot of CL electives then.

Now, you'd be a better teacher/researcher with somewhat better job prospects if you did the fellowship - but it's not entirely necessary either.

 

[whopper]

Geriatric and consult psychiatry will have you on your toes concerning medical conditions.

Forensic psychiatry will alienate you to medicine. I spent more time memorizing legal cases than doing anything close to medicine during fellowship. I went through medicine withdrawal, just like I went through behavioral science withdrawal in medical school, just like I went through art withdrawal in college (I decided to become a psychology major when I was originally convinced to be an illustrator).

Being on a geriatric unit was kind of a medicine shock to the system, and I had to relearn quite a bit of it. Thankfully, my partner attending on the unit is a dual family practice-psychiatrist and he is more than helpful and patient with me if I have questions.

 

[MrJiggles]

Hm alright. I guess if I plan on staying in NYC it behooves me to get a fellowship, everyone's a doc here. Lets see if I like the Psycho-Oncology thing, I'm trying out a rotation in it in the fall. Do any of you have any experience in this?

In any case this is all speculation far down the line, I have no idea where my path will lead. I was more wondering why there was a fast track for C/A but not for CL or other fellowships, it seems an odd double standard unless there is something I'm missing.

If length of training is your concern, you can skip the fellowship alltogether and still be able to do consults. This will be especially true if you go to a program with strong CL (quarternary referral center). 4th year is entirely elective most places and you could do a lot of CL electives then.

Now, you'd be a better teacher/researcher with somewhat better job prospects if you did the fellowship - but it's not entirely necessary either.

 

[vistaril]

Thanks nitemagi, splik, and notdeadyet. I suppose I agree, if my main goal is being a Psychiatrist, then I should focus on being great at that and go through training that affords me training in all aspects of psych such as psychotherapy as splik said. Admittedly, I do not know how the combined programs would actually even help me career, I don't really want to practice as an Internist or a Pediatrician, I simply want the breath of knowledge spans both physical and mental illness, making me a huge gunner...or a future CL Psych?

And you're right, every specialty loses some general medicine. On a side note, as I have an interest in CL-Psych, do any of you know if there is a "Fast-Track" in CL the way it is for Child/Adolescent? As in, could I start a CL fellowship in lieu of my 4th year of residency?

You cant leave your program for your pgy-4 and do the CL fellowship. If your program is anything like mine, however, the 4th year is mostly all electives and you could spend most of your time on C-L. Of course you would only want to do this if your C-L service was really educational.....

As for a C-L fellowship, it's not required...but it may help...depending on a lot of things. Many/most of the best people/biggest names in C-L in the country are not fellowship trained. Of course part of this is due to the fact that fewer people in general did the 1 year fellowships two decades ago, but still.........

I'll put it this way- If you want to do C-L, taking a junior faculty position right out of residency and getting to work in a strong C-L dept with some impressive C-L people some of the time would be a lot more helpful to building your career as a C-L psychiatriatrist than doing a fellowship at a lesser place for that year.

As for the "you get to keep up your medicine skills doing C-L" angle, I think this is overstated. If anything, someone with insecurities(as you seem to have on this issue) about medical training as a psychiatrist is often in a rough spot doing C-L because these insecurities are worsened on C-L service when you interact with other specialties......another frustrating thing about C-L, especially in academic medicine, is that 60% of the time the primary team doesnt really care what you think or say. That's just consulting you for one of a few other reasons....such as they want you to maybe serve as dispo/sw help/placement, they're just doing it "because", doing it to be nice, doing it to be mean and give others work, or doing it because they don't really know what the hell to do but are pretty sure you have nothing to offer either.

I won C-L resident of the year when I was doing C-L, and I can't tell you how many times I got a consult and said "what the hell do they want me to do with this"......

yes, I can see how it would be very satisfying to actually make recs that dramatically change the course of the pt's care and/or unlock some undiscovered aspect of treatment to the primary team. but this is *very rare* in C-L psychiatry.....95% of it is delirium recs(and decent internists can do their own delirium recs just fine), assessing safety to go home, making med recs for mood d/os that are really outpt in nature, etc...

 

[splik]

In any case this is all speculation far down the line, I have no idea where my path will lead. I was more wondering why there was a fast track for C/A but not for CL or other fellowships, it seems an odd double standard unless there is something I'm missing.

Residency is in general adult psychiatry. General adult psychiatry equips one to work with adults in the general hospital setting. There is no need for the fellowship, but obviously it is good training. You could do addiction psychiatry without an addiction fellowship either, but probably should. You cant do child psychiatry without a child fellowship. You spend what, 2 months during residency doing child otherwise. There is also a massive shortage of child psychiatrists, and child fellowship is 2 years, not 1. These are the reasons why fasttrack exists for child.

When I told one of my mentors (one of the leading C/L psychiatrists in the world) I wanted to do a psychosomatic medicine fellowship, he said 'why would you want to do that?' (mind you, i wanted an academic career so you are being employed for your grant-attaining ability, not how well trained you are clinically). That said, most of the psychiatrists on the C/L service where I am (which is one of the most established C/L services in the country) do not have a psychosomatic medicine fellowship. Conversely, another one of my mentors is the head of the c/l service at the most established consult psychiatry service in the country, but is a clinician, not an academic, said I should do a psychosomatic fellowship...

 

[vistaril]

Residency is in general adult psychiatry. General adult psychiatry equips one to work with adults in the general hospital setting. There is no need for the fellowship, but obviously it is good training. You could do addiction psychiatry without an addiction fellowship either, but probably should. You cant do child psychiatry without a child fellowship. You spend what, 2 months during residency doing child otherwise. There is also a massive shortage of child psychiatrists, and child fellowship is 2 years, not 1. These are the reasons why fasttrack exists for child.

When I told one of my mentors (one of the leading C/L psychiatrists in the world) I wanted to do a psychosomatic medicine fellowship, he said 'why would you want to do that?' (mind you, i wanted an academic career so you are being employed for your grant-attaining ability, not how well trained you are clinically). That said, most of the psychiatrists on the C/L service where I am (which is one of the most established C/L services in the country) do not have a psychosomatic medicine fellowship. Conversely, another one of my mentors is the head of the c/l service at the most established consult psychiatry service in the country, but is a clinician, not an academic, said I should do a psychosomatic fellowship...

decent post overall, but I think it's important to note that psychiatry fellowships(outside of c/a) werent that common a few decades ago.....so it's hard to predict what things will be like a couple decades from now.

I think one of the issues with psych fellowships is the ow quality in many quite frankly.....I know of programs that have fellowships in addiction, cl, and forensics that offered substandard training when the pgy2s rotated through there. And the "fellowship" isnt a whole lot more than a would be pgy5 rotating through again with a tad more responsibility.....from my perspective that is next to useless.....

in many psych "fellowships", you have fellows working under people who never did a fellowship......that kind of goes to how little the fellowship is required. Could you imagine a comparable situation where GI and cards fellows trained at fellowships where the supervisors didnt have fellowship training in those fields? Of course not......

 

[BS81]

Most people I've talked to say that unless you want to go in to academia fellowships outside of CA or forensics aren't really that necessary. Most addiction psychs in my area are specialized by the "addiction medicine" board which is still grandfathering people in by experience. On the other hand one of my attendings managed to turn a gero psych fellowship in to a lucrative private practice before going back to inpatient work. Sometimes being the only person with a fellowship in town will give you that extra boost in getting private patients.

 

[vistaril]

Most people I've talked to say that unless you want to go in to academia fellowships outside of CA or forensics aren't really that necessary. Most addiction psychs in my area are specialized by the "addiction medicine" board which is still grandfathering people in by experience. On the other hand one of my attendings managed to turn a gero psych fellowship in to a lucrative private practice before going back to inpatient work. Sometimes being the only person with a fellowship in town will give you that extra boost in getting private patients.

for people who want to do geri, a geri fellowship is a good idea.......

addiction is supposedly doing away with the grandfathering thing in a few years, but who really cares??? Its not going to matter from a practice standpoint. And quite frankly, what role medicine plays in addiction treatment is very much up for debate.

even if you want to stay in academia and do C-L in academia a C-L fellowship might now be the best route....

 

[MrJiggles]

Yeah its true, most I've talked to as well seem to be kind of ambivalent about the matter. The CL psych for the hospital I rotated through last wasn't fellowship trained. Oddly enough, he is the ONLY Psychiatrist for the whole hospital, he's kind of miserable and overworked. How do CL Psychs get compensated anyway in the age of ACOs, RVU's, and whatever other acronyms for cost-reduction? 5 years from now when I'm done with residency, the healthcare landscape will probably be pretty different.

 

[BS81]

CLs make less than most other psychs. They don't bring any revenue in to the hospitals, only theoretically save money in the long run.

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[vistaril]

Yeah its true, most I've talked to as well seem to be kind of ambivalent about the matter. The CL psych for the hospital I rotated through last wasn't fellowship trained. Oddly enough, he is the ONLY Psychiatrist for the whole hospital, he's kind of miserable and overworked. How do CL Psychs get compensated anyway in the age of ACOs, RVU's, and whatever other acronyms for cost-reduction?QUOTE]

C-L doesnt have a bright future from a financial perspective, but large academic hospitals will probably keep employing them(often at a loss) on salary because....well...just because.....in the private sector there will always be part time C-L contracts because in the real world(aka the private sector) C-L psychiatrists serve as medicolegal outs and dispo helpers..... iow in the private world C-L people function as some weird hybrid of a social worker and an insurance against lawsuits.....

 

[digitlnoize]

CLs make less than most other psychs. They don't bring any revenue in to the hospitals, only theoretically save money in the long run.

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I know a guy who does C-L work on the side of his inpatient and outpatient gigs. He has an interesting set up...

He does ~4h of community/private inpatient in the mornings, then goes to the private hospital and does some consults. Then, some days he does some outpatient work.

He works ~30h/wk and makes ~$230k from all sources and is always chill, not rushed, and happy. Pretty sweet gig.

 

[MrJiggles]

How to people get into a set-up like this anyway? I'd love to so some CL at an academic center and have my own private practice on the side, or something of the sort. The CL attending at my med school seems to do that, she works 4 mornings a week in CL, afternoons and friday in outpatient practice. Would getting a fellowship or a "top" residency help me leverage such an arrangement?

I know a guy who does C-L work on the side of his inpatient and outpatient gigs. He has an interesting set up...

He does ~4h of community/private inpatient in the mornings, then goes to the private hospital and does some consults. Then, some days he does some outpatient work.

He works ~30h/wk and makes ~$230k from all sources and is always chill, not rushed, and happy. Pretty sweet gig.

 

[whopper]

Some people do. A problem with my current setup is the University makes you work for them completely if you're full-time. If you do part-time they greatly hinder your ability to get choice rotations.

I know a few people doing the above setup. 230K with the above setup is completely realistic I know some buddies that tried to get me into a CL gig at a local hospital where we would get paid her consult and it was quite lucrative. Mix that up with another gig and I can easily see someone making 230K.

My advice is whatever job you get, don't lock yourself into it as if there's no other job opportunities because something like the above is out there if you look, but you have to know where and how.

 

[DOC PENGUIN]

Didn't Anazi23 already write something about this? There was a question on the real doctor issue and he say hew did INT regularly: IV, Vaccines, Blood pressure (the stuff "real" doctors do)

 

[OldPsychDoc]

Didn't Anasazi23 already write something about this? There was a question on the real doctor issue and he say hew did INT regularly: IV, Vaccines, Blood pressure (the stuff "real" doctors do)

Here is 'Sazi's classic post, at least the one that I recall.

 

[whopper]

he is the ONLY Psychiatrist for the whole hospital, he's kind of miserable and overworked

If I were him, I'd tell the hospital that I'm cutting my hours, be polite and diplomatic about it, state it's nothing personal and that I need my sanity. They could of course try to entice me to work hard by paying me more.

 

[MrJiggles]

Here is 'Sazi's classic post, at least the one that I recall.

That is one of the best posts I've ever read on an online forum. Alright, I have my CL "Sub-I" next, now I'm pumped haha.




Yeahhh the Psychiatrist I previously mentioned probably should cut his hours, I'm close to some of the admins and they said they've actually had a tough time finding people to fill the position. Is CL not a popular sub-specialty? I'd imagine a lot of folks would want to do it, but I guess I like being in the hospital and am biased.

 

[whopper]

At one hospital I worked at, the administration worked a doctor as much as they could to the point of exploitation. I don't recommend ever being confrontational with bosses (unless it's an extreme situation) because then the administration just won't want you period, but if you do a good job, they'll want to keep you. If there's no one else (and this is often the case) they'll be desperate to hold onto you. IF you allow some people to walk over you, they'll walk over you.

 

[vistaril]

That is one of the best posts I've ever read on an online forum. Alright, I have my CL "Sub-I" next, now I'm pumped haha.
.

the most telling part of the post, imo, is when it starts "I always find it kind of surprising when I see posts like this"(meaning posts that question the linkage between psychiatry and the medical model/medical school/being a "real doctor").....the fact that every month there seems to be at least one thread started on the subject(started by different people) should tell you something about perception.

if people are always "surprised" at how other professionals, physicians, med students, etc don't view psychiatry in the same way as other fields of medicine, maybe it's time to stop being surprised.......

When people ask me the big question(why didnt I want to do something more in line with being a real doctor), I just say "because I like doing this more".......I certainly would never try to claim what I'm doing is similar to what a pulmonlogist or surgeon does....

 

[digitlnoize]

Is CL not a popular sub-specialty?

Not really. Most people opt for adult outpatient psych. It's faster (4 years, instead of 5), plus it's fairly profitable, which C-L psych isn't always, for various reasons. I do think most of us enjoy it, at least in theory.

if people are always "surprised" at how other professionals, physicians, med students, etc don't view psychiatry in the same way as other fields of medicine, maybe it's time to stop being surprised.......

I've found that the people being surprised are usually simply uninformed. So little emphasis is placed on psych at most medical schools, and in medical training in general, that we can hardly blame medical students for their ignorance up until the day they do their first C-L rotation.

I think it just comes with the territory, and I try to educate every student (and even patients) that I talk to about the breadth of psych.