How to maximize psych training in FM?

[Sardonix]

I'm a med student. As I approach application season next year, I've found I really enjoy psych and addiction med among many other aspects of FM. While I understand I could always apply to a psych residency, I also like other parts of medicine in FM and aren't ready to leave them behind (also Match is getting scary).

Aside from adding psych rotations in 4th year and applying to dual FM-psych residencies (which seem to me like longer residencies that ultimately lead to regular psych practice anyway) what are other ways for FM doctors to increase the breadth of their psych patients/practice?

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[TheOther]

Programs vary in strengths and focused training. I can’t name exact ones since I applied to a narrow geographic region and psych wasn’t a top priority for me, but I’ve heard of plenty of programs that have excellent behavioral medicine training. Plus, you can use electives throughout residency to spend additional time on psych.

 

[AMEHigh]

Electives during residency, conferences and CME. Many (most?) family docs have a topic that they’re more interested in/focused on (the beauty of family med!) so it’s easy to have a little more focus in 1 area. The AAFP also has special member interest groups that are good to join to attend meetings and be on message boards with family med physicians who are like minded.

In addition, I have a specific interest and we have Facebook groups and an email list serve that’s very active. So there are plenty of ways to stay interested in psych within family med. It’s definitely a much needed area!

 

[Splenda88]

You can do an addiction fellowship... As an IM resident, I plan to do one.

 

[Sardonix]

You can do an addiction fellowship... As an IM resident, I plan to do one.

I'm very interested in it. Just gotta make sure I have the right stuff for it before thinking more seriously on it.

 

[GEToutLADYits6AM]

Do a psych residency stoopid

 

[Sushirolls]

I'm a med student. As I approach application season next year, I've found I really enjoy psych and addiction med among many other aspects of FM. While I understand I could always apply to a psych residency, I also like other parts of medicine in FM and aren't ready to leave them behind (also Match is getting scary).

Aside from adding psych rotations in 4th year and applying to dual FM-psych residencies (which seem to me like longer residencies that ultimately lead to regular psych practice anyway) what are other ways for FM doctors to increase the breadth of their psych patients/practice?

I like your interests and applaud the combination. However, there is no substitute for a psych residency. Even the Addiction Medicine fellowships (now boarded thru the ABPM) are deficient in the core psychiatric symptoms many of the patients exhibit.

At best family medicine residencies have 1-2 months of electives per training year, more commonly 0-1 elective. Few if any elect for a psych rotation, and few programs have them available. Even if you are the one in a million family medicine resident who does take advantage of it, do you do inpatient? Consultation & Liasion? Community mental health outpatient? General outpatient? Psych ED? Forensics? Child & Adolescent Inpatient? Child & Adolescent outpatient? Geriatric Inpatient? Eating Disorder clinic? Chemical dependency detox? Child and adolescent addiction inpatient? Rehab? Chronic pain rehabilitation unit? And if at a place with multiple inpatient options do you do the mood disorder, more severe mental illness disorder unit?

The complete exposure in a psychiatry residency encapsulates all of these types of rotations that approximates the full spectrum of mental illness. Catching just one of these rotations will be helpful, but not likely to yield a psych focused FM.

In my personal opinion, going off the assumption that at least 1/3 of primary care involves some level of psychiatry, current training programs are grossly deficient and should have a minimum of 4 months psychiatry in the 3 year training. 1mo inpatient, 1mo outpatient, 1mo C&L, 1mo Psych ED.

 

[VA Hopeful Dr]

I like your interests and applaud the combination. However, there is no substitute for a psych residency. Even the Addiction Medicine fellowships (now boarded thru the ABPM) are deficient in the core psychiatric symptoms many of the patients exhibit.

At best family medicine residencies have 1-2 months of electives per training year, more commonly 0-1 elective. Few if any elect for a psych rotation, and few programs have them available. Even if you are the one in a million family medicine resident who does take advantage of it, do you do inpatient? Consultation & Liasion? Community mental health outpatient? General outpatient? Psych ED? Forensics? Child & Adolescent Inpatient? Child & Adolescent outpatient? Geriatric Inpatient? Eating Disorder clinic? Chemical dependency detox? Child and adolescent addiction inpatient? Rehab? Chronic pain rehabilitation unit? And if at a place with multiple inpatient options do you do the mood disorder, more severe mental illness disorder unit?

The complete exposure in a psychiatry residency encapsulates all of these types of rotations that approximates the full spectrum of mental illness. Catching just one of these rotations will be helpful, but not likely to yield a psych focused FM.

In my personal opinion, going off the assumption that at least 1/3 of primary care involves some level of psychiatry, current training programs are grossly deficient and should have a minimum of 4 months psychiatry in the 3 year training. 1mo inpatient, 1mo outpatient, 1mo C&L, 1mo Psych ED.

Tht seems wildly unnecessary. By that logic, since probably a third of my patients have hypertension I should do 8 months of cardiology/nephrology rotations.

Our pysch training, like most of our training, takes place every day. During clinic time, we see patients with psychiatric pathology. During inpatient time, we see patients with psychiatric pathology.

This has the advantage of having us manage patients at the level that we will seeing once residency is over. Basically none of us are going to be working in psych EDs or on CL services.

What we will be doing is seeing patients in a primary care setting. Makes sense that we train while seeing patients in that same setting.

 

[Sushirolls]

I wish it were unnecessary. The exposure to those rotations will better help approximate the range of care that patients interface with mental health treatment. Understanding those intersections can help guide the management at the primary care level.

8 months of cardiology isn't necessary because the bulk of the specialty is algorithmic.

A large part of my job is undoing what primary care has done be it diagnosis or med management. I'm not here trying to ruin corn flakes. My summary point I'm trying to make is management in primary care for mental health has room to improve and I believe one possible solution is greater exposure in residency.

 

[betamale]

There are behavioral health fellowships for family docs. Go to the AAFP fellowship site

More power to you. Hate psych, eww

 

[Sardonix]

I wish it were unnecessary. The exposure to those rotations will better help approximate the range of care that patients interface with mental health treatment. Understanding those intersections can help guide the management at the primary care level.

8 months of cardiology isn't necessary because the bulk of the specialty is algorithmic.

A large part of my job is undoing what primary care has done be it diagnosis or med management. I'm not here trying to ruin corn flakes. My summary point I'm trying to make is management in primary care for mental health has room to improve and I believe one possible solution is greater exposure in residency.

Which brings us back to my original question: how might I go about increasing that exposure to psychiatry.

Needless to say, an FM residency is not going to make me comparable to a full psych residency. But I'm asking how FM can go about increasing their psych expertise so, at the very least, they part of the solution and not the problem you describe.

 

[VA Hopeful Dr]

I wish it were unnecessary. The exposure to those rotations will better help approximate the range of care that patients interface with mental health treatment. Understanding those intersections can help guide the management at the primary care level.

8 months of cardiology isn't necessary because the bulk of the specialty is algorithmic.

A large part of my job is undoing what primary care has done be it diagnosis or med management. I'm not here trying to ruin corn flakes. My summary point I'm trying to make is management in primary care for mental health has room to improve and I believe one possible solution is greater exposure in residency.

So now the question becomes did those primary care docs whose messes you are fixing get into trouble because of lack of training or because of something else.

Given the 10 minute appointments most of us deal with, the 25-30 patients/day, and the fact that most of our patients don't come in with just 1 problem... I think I know the answer.

 

[betamale]

Psychiatry – Family Medicine Fellowship

Psychiatry – Family Medicine Fellowship

www.columbiapsychiatry.org

UTMB

Available Fellowships

PaRC Discovery - Drug & Alcohol Rehab Treatment in Houston, Texas

Recover from addiction at PaRC in Houston ,Texas, formerly part of Memorial Hermann. We have a nearly 40-year, award-winning history of treating alcoholism, drug addiction and dual diagnosis.

parc.memorialhermann.org

UC Davis/UC Irvine Train New Trainers Primary Care Psychiatry Fellowship

I personally think that 6 months of family medicine residency should be turned into a mini-fellowship of your choice similar to how radiology residencies

Our subspecialty faculty dedicate 1 or 2 day clinics for their specialty, ie, women's health procedures, sports, diabetes...

 

[Sardonix]

Psychiatry – Family Medicine Fellowship

Psychiatry – Family Medicine Fellowship

www.columbiapsychiatry.org

UTMB

Available Fellowships

PaRC Discovery - Drug & Alcohol Rehab Treatment in Houston, Texas

Recover from addiction at PaRC in Houston ,Texas, formerly part of Memorial Hermann. We have a nearly 40-year, award-winning history of treating alcoholism, drug addiction and dual diagnosis.

parc.memorialhermann.org

Primary Care Behavioral Health Fellowship

familymedicine.umn.edu

I personally think that 6 months of family medicine residency should be turned into a mini-fellowship of your choice similar to how radiology residencies

Our subspecialty faculty dedicate 1 or 2 day clinics for their specialty, ie, women's health procedures, sports, diabetes...

Thank you so much! Never thought I'd find a fellowship idea I'd like!

 

[AFMD]

If you are obsessed with psych, then do that. Otherwise, if you are interested in everything but like psych, then do family. If you are interested in academics, then that might change your calculus.

Your interests will change over time anyway. Every family doctor is interested in one or two things above everything else, as mentioned above.

Do a psych ED rotation somewhere at some point if you can. Treat addiction and psych issues like any other chronic disease in your outpatient clinic. Find mentors. Obtain a buprenorphine waiver.

I've thought about an addiction fellowship or simply getting the hours and taking the test right now, but ultimately I decided against it. I enjoy variety. I also think that's it's silly to use my time on training I already have in an incredibly common chronic disease. I'm not doing a fellowship in diabetes or COPD either.

 

[Sardonix]

If you are obsessed with psych, then do that. Otherwise, if you are interested in everything but like psych, then do family. If you are interested in academics, then that might change your calculus.

Your interests will change over time anyway. Every family doctor is interested in one or two things above everything else, as mentioned above.

Do a psych ED rotation somewhere at some point if you can. Treat addiction and psych issues like any other chronic disease in your outpatient clinic. Find mentors. Obtain a buprenorphine waiver.

I've thought about an addiction fellowship or simply getting the hours and taking the test right now, but ultimately I decided against it. I enjoy variety. I also think that's it's silly to use my time on training I already have in an incredibly common chronic disease. I'm not doing a fellowship in diabetes or COPD either.

The bold definitely describes me. I have an inpatient/ED psych rotation lined up next year so I guess that's covered.

Your other insights are also interesting. Like I said, in addition to liking psych I also enjoy addiction med BUT I haven't yet seen it day-in-day-out so we'll see if I'm actually cut out for it.

 

[AMEHigh]

I wish it were unnecessary. The exposure to those rotations will better help approximate the range of care that patients interface with mental health treatment. Understanding those intersections can help guide the management at the primary care level.

8 months of cardiology isn't necessary because the bulk of the specialty is algorithmic.

A large part of my job is undoing what primary care has done be it diagnosis or med management. I'm not here trying to ruin corn flakes. My summary point I'm trying to make is management in primary care for mental health has room to improve and I believe one possible solution is greater exposure in residency.

I’m genuinely curious what you expect us in primary care to do for our patients with mental health needs since apparently we’re doing it all wrong and you have to undo all of our work?

We obviously can’t have 4 months of training in every single speciality that we take care of, the time just isn’t there.

I personally wouldn’t mind referring out most of my patients who have mental health illnesses to psychiatry, but do you know how difficult that would be? I’m in a suburb of a large city that has almost the most hospitals in the country, yet it is virtually impossible for my patients to get a psychiatry appointment. It seems over half of them don’t take insurance, definitely don’t take state insurance and then if they do the waiting list is over 6 months.

So if I think some has anxiety, depression or even bipolar disorder based on a thorough assessment I am definitely going to treat them based on my clinical knowledge and not let them suffer. I also always encourage my patients to see our psychologist so that they can help to confirm the diagnosis and we can work together on the treatment plan. I wouldn’t not treat someone with COPD if they couldn’t get in with a pulmonologist for 6 months.

What are psychiatrists saying/doing about this lack of access?

 

[Sushirolls]

These are deficiencies that are reflective of the health system as a whole. My intent is not to belittle the efforts family medicine is doing in good faith to the best of their ability. I applaud the good faith efforts.

-Family medicine residencies can expand their rotations in psychiatry to 4 months. This would be a good change.
-Immediate changes can be things like not prescribing benzodiazapines, especially xanax.
-Keeping diagnoses generic like unspecified depressive disorder. Or for possible Bipolar patients, using the DSM-IV diagnosis Unspecified Mood Disorder. This helps decrease the attachment patients will develop towards identifying as "I am Bipolar" when in fact, they have an Axis II personality disorder and really need to emphasize DBT as the intervention of choice.

-Psychiatrists are continuing to push for insurance parity. We are unfortunately the forgotten and disregarded specialty. Insurance companies will pay us less, or inundate us with more prior auths for medications - despite high approval rates - and other treatment plan paperwork.
-Even the most effective intervention for depression, ECT, is treated as a second class citizen, and not on the CMS list for ambulatory surgery centers. So one of the safest procedures - has to be performed in hospitals. I've urged the ECT society, and they the APA to push them to add to their list but they don't care and isn't a priority. So this is decreased access to a life saving, and 'disability' relieving procedure.
-TMS is FDA approved but continues to be 10x the paperwork of ECT to get authorized and insurance companies have it typically needed Single Case Agreements. I.e. more bureaucracy to thwart treatment options.
-Even myself, I do lengthy consults with my practice and at times use the 99354 code - but the insurance companies don't pay. There goes 30-60 minutes extra of work that's not reimbursed.
-Health systems are typically antiquated and only see the bottom line of losing money on psych departments, and not the system wide cost savings they provide in overall well being for patients who happen to be some of the highest cost utilizers. For instance, I spent several years practicing in old derilect building that had rats in toilets, heat that didn't work, or air conditioning that didn't work to the detriment of patients health.
-I've personally met with every administrator I could at one health system pleading for job adjustment to be able to meet the community needs of the Opioid Epidemic - and no one cared.
-I've also met with another health system trying to start up an ECT service - and told not part of their long term plans 'bye, bye.' Despite the locality being a proven boon to the financial bottom line and their original delighted interest.
-I also volunteered to the Admin at a previous health system, to funnel their chronic pain opioid complex patients, so I can assist in taper recommendations and non-opioid med maximization for chronic pain and again, they didn't care. I was more valuable on the inpatient unit then these ancillary services lines.

-The deficiency of psychiatrists is a mixed issue that equal effects primary care. Bottle neck of residencies. The solution is ending GME funding from CMS and permitting the growth of a more job/work based type training system in its ashes.
-The deficiency of psychiatrists is also packaged into the american legal system. If I didn't have to document for lawyers or billing companies- but only for clinical purposes I could see twice as many patients.
-The deficiency of psychiatrists can also be met in part by shifting to a heavier consult role. Do a single consult with solid recommendations to carry through for the FM to implement, but these types of consults can be lengthy - and system wise insurance companies just don't want to put us for our services.

Both FM and Psych are facing the loss of their clinicians to cash only, limited insurance practices, direct access, concierge, retainer style, what ever you want to call it. The system as a whole is burning out doctors and psychiatrists ares just a little quicker to not tolerate the BS.

 

[Drrrrrr. Celty]

These are deficiencies that are reflective of the health system as a whole. My intent is not to belittle the efforts family medicine is doing in good faith to the best of their ability. I applaud the good faith efforts.

-Family medicine residencies can expand their rotations in psychiatry to 4 months. This would be a good change.
-Immediate changes can be things like not prescribing benzodiazapines, especially xanax.
-Keeping diagnoses generic like unspecified depressive disorder. Or for possible Bipolar patients, using the DSM-IV diagnosis Unspecified Mood Disorder. This helps decrease the attachment patients will develop towards identifying as "I am Bipolar" when in fact, they have an Axis II personality disorder and really need to emphasize DBT as the intervention of choice.

-Psychiatrists are continuing to push for insurance parity. We are unfortunately the forgotten and disregarded specialty. Insurance companies will pay us less, or inundate us with more prior auths for medications - despite high approval rates - and other treatment plan paperwork.
-Even the most effective intervention for depression, ECT, is treated as a second class citizen, and not on the CMS list for ambulatory surgery centers. So one of the safest procedures - has to be performed in hospitals. I've urged the ECT society, and they the APA to push them to add to their list but they don't care and isn't a priority. So this is decreased access to a life saving, and 'disability' relieving procedure.
-TMS is FDA approved but continues to be 10x the paperwork of ECT to get authorized and insurance companies have it typically needed Single Case Agreements. I.e. more bureaucracy to thwart treatment options.
-Even myself, I do lengthy consults with my practice and at times use the 99354 code - but the insurance companies don't pay. There goes 30-60 minutes extra of work that's not reimbursed.
-Health systems are typically antiquated and only see the bottom line of losing money on psych departments, and not the system wide cost savings they provide in overall well being for patients who happen to be some of the highest cost utilizers. For instance, I spent several years practicing in old derilect building that had rats in toilets, heat that didn't work, or air conditioning that didn't work to the detriment of patients health.
-I've personally met with every administrator I could at one health system pleading for job adjustment to be able to meet the community needs of the Opioid Epidemic - and no one cared.
-I've also met with another health system trying to start up an ECT service - and told not part of their long term plans 'bye, bye.' Despite the locality being a proven boon to the financial bottom line and their original delighted interest.
-I also volunteered to the Admin at a previous health system, to funnel their chronic pain opioid complex patients, so I can assist in taper recommendations and non-opioid med maximization for chronic pain and again, they didn't care. I was more valuable on the inpatient unit then these ancillary services lines.

-The deficiency of psychiatrists is a mixed issue that equal effects primary care. Bottle neck of residencies. The solution is ending GME funding from CMS and permitting the growth of a more job/work based type training system in its ashes.
-The deficiency of psychiatrists is also packaged into the american legal system. If I didn't have to document for lawyers or billing companies- but only for clinical purposes I could see twice as many patients.
-The deficiency of psychiatrists can also be met in part by shifting to a heavier consult role. Do a single consult with solid recommendations to carry through for the FM to implement, but these types of consults can be lengthy - and system wise insurance companies just don't want to put us for our services.

Both FM and Psych are facing the loss of their clinicians to cash only, limited insurance practices, direct access, concierge, retainer style, what ever you want to call it. The system as a whole is burning out doctors and psychiatrists ares just a little quicker to not tolerate the BS.

This was... special.

 

[simpler2]

To the OP: I had similar interests in training (and still do). I arranged that most of my electives were in mental health/addiction and spent about 6 months of residency in these areas. After completion of training, I went to work in an area with lack of access to psychiatry consultation so more comprehensive practice became a necessity. Due to the large addiction focus that my practice took on over time, I was able to board certify in addiction medicine via the practice pathway.

Sushirolls is making some interesting points but I don't feel they are relevant or reflect the reality of mental health care in my region/practice. If you would like more details on my path, feel free to PM.

 

[FrustratedFamDoc]

I had a very thorough psych training and came out comfortable enough to handle 90% of the common stuff. I trained at an unopposed community program and my month of psych entailed shadowing a community psychiatrist in his private office. I learned through my preceptors and what I saw in clinic 2- 3 days a week.

When psychiatrists say that PCPs screw up patients, what they really mean is polypharmacy and benzos isn't a good way to go. And it's not. And hopefully, most new grads know that. Avoid polypharmacy and benzos and you'll avoid this label. Incidentally, I see far more polypharmacy zombification from psychiatrists than I do from new patients coming to see me from another PCP but that's all I have to say about that.

 

[Sardonix]

I had a very thorough psych training and came out comfortable enough to handle 90% of the common stuff. I trained at an unopposed community program and my month of psych entailed shadowing a community psychiatrist in his private office. I learned through my preceptors and what I saw in clinic 2- 3 days a week.

When psychiatrists say that PCPs screw up patients, what they really mean is polypharmacy and benzos isn't a good way to go. And it's not. And hopefully, most new grads know that. Avoid polypharmacy and benzos and you'll avoid this label. Incidentally, I see far more polypharmacy zombification from psychiatrists than I do from new patients coming to see me from another PCP but that's all I have to say about that.

I too am confused by this. During my psych rotation, the only time I have seen patients stop taking their BZDs is when they have a DIFFERENT additional benzo on their med list as a back up.

Otherwise it's a very casual "Hey doesn't look like you need Ativan anymore, how about we stop it?" "No" "Cool, see you in three months!"

 

[Drrrrrr. Celty]

I had a very thorough psych training and came out comfortable enough to handle 90% of the common stuff. I trained at an unopposed community program and my month of psych entailed shadowing a community psychiatrist in his private office. I learned through my preceptors and what I saw in clinic 2- 3 days a week.

When psychiatrists say that PCPs screw up patients, what they really mean is polypharmacy and benzos isn't a good way to go. And it's not. And hopefully, most new grads know that. Avoid polypharmacy and benzos and you'll avoid this label. Incidentally, I see far more polypharmacy zombification from psychiatrists than I do from new patients coming to see me from another PCP but that's all I have to say about that.

I honestly don't think managing a lot of psychiatric conditions is necessarily difficult, especially for many vanilla cases. Like I did 4 psych rotations last year and I honestly I didn't actually learn much more than what was in First Aid for Psych aside from improving interview techniques mildly. Well that and just how pitiful the mental health infrastructure in this country is.

I think however it's hard to compare a pt who needs a psychiatrist and is likely very sick to someone who is managed by pcp. Very sick pts are going to be difficult to manage and the line between relapsing into an episode or going on substances again is very high. A high strung person who wants their xanax is less so.

 

[FrustratedFamDoc]

I too am confused by this. During my psych rotation, the only time I have seen patients stop taking their BZDs is when they have a DIFFERENT additional benzo on their med list as a back up.

Otherwise it's a very casual "Hey doesn't look like you need Ativan anymore, how about we stop it?" "No" "Cool, see you in three months!"

My approach for benzos has been far more firm the longer I practice.

"Here's why this is a terrible choice for a daily medicine for you. Here's how it has screwed you up. Here's what you can expect if you continue on with this. My plan is to have you off of this garbage in the next few months and after that, I will not write it any longer. If you're ok with this then please continue to see me. If not, then we may not work out."

The more benzos you write, the more benzo hooked patients you'll have coming to see you. That's a negative, Ghostrider.

 

[clausewitz2]

I too am confused by this. During my psych rotation, the only time I have seen patients stop taking their BZDs is when they have a DIFFERENT additional benzo on their med list as a back up.

Otherwise it's a very casual "Hey doesn't look like you need Ativan anymore, how about we stop it?" "No" "Cool, see you in three months!"

Your psych rotation was kind of weak, then.

Contra a poster below, anyone can just threaten to cut off someone's benzos. The trick is weaning them off in such a way that you get buy-in from them and they don't immediately start shopping around for someone who will write them.

Additionally, say they were put on bzds originally for their anxiety. What is your alternate treatment? SSRIs are never going to convince someone that they do not miss their Valium. What do you do when they come in saying they cannot stand the nervousness and they aren't sleeping and their mood is all over the place?

No, seriously, FM folks who feel stopping Klonopin is no big deal, what is your approach given you have maybe 15 minutes to talk to them about this every few months? Some of y'all might have well-trained therapists in your office or an easy referral, but that is not true for all practices at least in this neck of the woods.

 

[deleted87716]

The trick is weaning them off in such a way that you get buy-in from them and they don't immediately start shopping around for someone who will write them.

You say that like it's a bad thing.

 

[clausewitz2]

You say that like it's a bad thing.

I appreciate that it would almost certainly add months back onto your own life not to have to deal with situations like this. At the same time, I think it is easy to say "I can handle 90% of psych stuff" if the solution is "GTFO of my clinic."

Also harm reduction etc etc

 

[deleted87716]

Well, the best way to avoid having benzo-dependent patients is not to prescribe chronic benzos in the first place. That's what I call harm reduction.

If getting patients hooked on benzos is part of the psych stuff that I can't handle, then you're welcome to it.

 

[Mad Jack]

Which brings us back to my original question: how might I go about increasing that exposure to psychiatry.

Needless to say, an FM residency is not going to make me comparable to a full psych residency. But I'm asking how FM can go about increasing their psych expertise so, at the very least, they part of the solution and not the problem you describe.

Exposure is key and there really isn't a good way to do it within most residencies. As was said previously, psych isn't like cardiology or nephrology. The only real way to know the illnesses you're working with is to see them directly, which allows you to delineate them properly. Psych rotations on the FM service are a poor approximation, as you're generally heavily supervised and don't really get into the thought process behind psychiatry as much as you have to when you're a resident flying solo. To get more exposure you could do one of the unofficial primary care behavioral health fellowships out there. Psych is very, very challenging, far more than I realized going in. Diagnoses and prescribing are very nuanced, and it takes a lot of dedicated time to learn. Worse still is that people assume outpatient prescribing is easy when it is more challenging than inpatient prescribing by a long shot.

 

[Mad Jack]

I had a very thorough psych training and came out comfortable enough to handle 90% of the common stuff. I trained at an unopposed community program and my month of psych entailed shadowing a community psychiatrist in his private office. I learned through my preceptors and what I saw in clinic 2- 3 days a week.

When psychiatrists say that PCPs screw up patients, what they really mean is polypharmacy and benzos isn't a good way to go. And it's not. And hopefully, most new grads know that. Avoid polypharmacy and benzos and you'll avoid this label. Incidentally, I see far more polypharmacy zombification from psychiatrists than I do from new patients coming to see me from another PCP but that's all I have to say about that.

There are a lot of bad prescribers out there, which I credit to the era of people going into psych as a backup without actually caring about the field. Sometimes people need a truly complex regimen, but more often than not polypharmacy is trouble when you're reviewing a med rec

 

[clausewitz2]

Well, the best way to avoid having benzo-dependent patients is not to prescribe chronic benzos in the first place. That's what I call harm reduction.

If getting patients hooked on benzos is part of the psych stuff that I can't handle, then you're welcome to it.

I agree with you about minimizing benzos, but recall: @mark v was talking about his approach to patients -already- taking benzos, not starting them. That is an entirely different situation but unless I misunderstood him very badly he was providing his spiel he gives to people (I am assuming new-ish patients) who are establishing care when he cuts them off (gradually, of course). He seemed to be saying this was a simple process

Sometimes this will work nicely and I commend him for at least having the conversation. But do you all feel equally comfortable with handling the situation when it doesn't? Rapid tapers increase the chances that it won't go well, often because patients do not tolerate it.

From a making your life easier perspective, if they go elsewhere, fine, you have fewer gray hairs. But is it actually helping to try and taper them if they just end up finding the local candyman? (sometimes a psychiatrist, for sure, but the distribution of docs in this country alone means it's going to be a PCP a lot of the time). There may be situations where leaving the Librium alone until you can find a good referral is warranted.

I am not trying to attack FM at all, you guys are awesome. I just worry that assertions about how you can basically handle almost all psych issues in your office are maybe overstating the case.

 

[VA Hopeful Dr]

I agree with you about minimizing benzos, but recall: @mark v was talking about his approach to patients -already- taking benzos, not starting them. That is an entirely different situation but unless I misunderstood him very badly he was providing his spiel he gives to people (I am assuming new-ish patients) who are establishing care when he cuts them off (gradually, of course). He seemed to be saying this was a simple process

Sometimes this will work nicely and I commend him for at least having the conversation. But do you all feel equally comfortable with handling the situation when it doesn't? Rapid tapers increase the chances that it won't go well, often because patients do not tolerate it.

From a making your life easier perspective, if they go elsewhere, fine, you have fewer gray hairs. But is it actually helping to try and taper them if they just end up finding the local candyman? (sometimes a psychiatrist, for sure, but the distribution of docs in this country alone means it's going to be a PCP a lot of the time). There may be situations where leaving the Librium alone until you can find a good referral is warranted.

I am not trying to attack FM at all, you guys are awesome. I just worry that assertions about how you can basically handle almost all psych issues in your office are maybe overstating the case.

There's your mistake. No one said almost all psych issues.

I had a very thorough psych training and came out comfortable enough to handle 90% of the common stuff. I trained at an unopposed community program and my month of psych entailed shadowing a community psychiatrist in his private office. I learned through my preceptors and what I saw in clinic 2- 3 days a week.

90% of the common stuff. Meaning most of the time we can handle most depressive and anxiety disorders.

 

[FrustratedFamDoc]

Never did I say the process is simple. On the contrary, it is almost always quite painful. Being 'helpful' for our patients can be defined in many different ways. To me, it's no different than the new patient that comes to see you who has been on 120 mg of Adderall/day (of course with a suitable large dose of a downer so they can sleep at night) or the beet red gentleman receiving 600 mg test injections (PSA now 10 and a hgb of 19.5) weekly. Both will tell you how helpful it has been for them. How it "turned my life around." Are you really helping those people by continuing that malpractice? What are your alternatives there? If all benzos went sched 1 tomorrow, would you celebrate or cry?

Do I have some patients on chronic benzos? Of course, all family docs do. Probably less than 15. Mostly older patients where the harm/help benefit is dubious if I were to try a taper so we leave it be.

We all have a choice to how we practice. If someone wants to go to the local candyman I'm 1000% good with that. We all make choices. Chances are, they were probably looking for that in the first place and probably wasted their time when they came to see me. Why should I be forced to practice what I consider to be bad medicine just because it's what the patient's last doc did?

 

[clausewitz2]

There's your mistake. No one said almost all psych issues.


90% of the common stuff. Meaning most of the time we can handle most depressive and anxiety disorders.

That I can agree with. Most of those people don't need a psychiatrist and I would argue are not really mentally ill.

 

[clausewitz2]

Never did I say the process is simple. On the contrary, it is almost always quite painful. Being 'helpful' for our patients can be defined in many different ways. To me, it's no different than the new patient that comes to see you who has been on 120 mg of Adderall/day (of course with a suitable large dose of a downer so they can sleep at night) or the beet red gentleman receiving 600 mg test injections (PSA now 10 and a hgb of 19.5) weekly. Both will tell you how helpful it has been for them. How it "turned my life around." Are you really helping those people by continuing that malpractice? What are your alternatives there? If all benzos went sched 1 tomorrow, would you celebrate or cry?

Do I have some patients on chronic benzos? Of course, all family docs do. Probably less than 15. Mostly older patients where the harm/help benefit is dubious if I were to try a taper so we leave it be.

We all have a choice to how we practice. If someone wants to go to the local candyman I'm 1000% good with that. We all make choices. Chances are, they were probably looking for that in the first place and probably wasted their time when they came to see me. Why should I be forced to practice what I consider to be bad medicine just because it's what the patient's last doc did?

I'm a psychiatrist - you'll get no argument from me that people's idea of what helps them may not line up with more objective evidence. Deprescribing is in most cases a mitzvah. But doing it well and making it stick in the case of dependence-inducing substances takes time and repeated contacts - how much time do you end up spending with these folks exploring the role these things play in their lives?

Harm reduction would suggest to me that I should certainly work with most of these patients towards tapering, but if on balance whatever I do results in a cumulative lower dose of these drugs over time that is much more important than my moral purity.

I would argue that it is your older patients who especially need to not be taking benzos because of the accompanying cognitive impairment and fall risk but that is another discussion.

Overall it is just not as black and white as you are making it out to be. Benzos do not equal malpractice.

 

[Drrrrrr. Celty]

Exposure is key and there really isn't a good way to do it within most residencies. As was said previously, psych isn't like cardiology or nephrology. The only real way to know the illnesses you're working with is to see them directly, which allows you to delineate them properly. Psych rotations on the FM service are a poor approximation, as you're generally heavily supervised and don't really get into the thought process behind psychiatry as much as you have to when you're a resident flying solo. To get more exposure you could do one of the unofficial primary care behavioral health fellowships out there. Psych is very, very challenging, far more than I realized going in. Diagnoses and prescribing are very nuanced, and it takes a lot of dedicated time to learn. Worse still is that people assume outpatient prescribing is easy when it is more challenging than inpatient prescribing by a long shot.

I can agree with this slightly. My experience on inpatient Sub-Is where I had almost entire autonomy allowed me to really get a solid perspective on the generally inclusive thinking required for diagnosing. This is probably the major difference where as in many fields it's far more deductive. Appreciating the difference between and how substance abuse or personality disorder can flavor and cause a patient to appear nearly psychotic or delusional is not something you get by following around a few patients.

That being said you and Claws are both really kind of making out a very perfect non generalizable and non applicable to real world psychiatry. Lots of psychiatrists I've known have missed personality disorders, explained diagnosis in non-dsm fashions, and generally prescribed medications as they felt ex. gabapentin or topamax for bipolar 1. Or worse I've seen doctors add on absurdist regiments at major university centers like, well you're still anxious so buspar, then gabapentin, then topamax. Calling that nuanced isn't correct, it's downright avant garde.

 

[deleted87716]

That I can agree with. Most of those people don't need a psychiatrist and I would argue are not really mentally ill.

A lot of them just lack resilience. It's a societal defect. But, hey...if they don't want to go to therapy, SSRIs also have a hella good placebo effect...

 

[clausewitz2]

A lot of them just lack resilience. It's a societal defect. But, hey...if they don't want to go to therapy, SSRIs also have a hella good placebo effect...

While I would use less moralistic language, I do agree that these are the people who back in the day would be diagnosed with neurasthenia.

 

[deleted87716]

While I would use less moralistic language, I do agree that these are the people who back in the day would be diagnosed with neurasthenia.

Or just told to suck it up.

 

[Mad Jack]

I can agree with this slightly. My experience on inpatient Sub-Is where I had almost entire autonomy allowed me to really get a solid perspective on the generally inclusive thinking required for diagnosing. This is probably the major difference where as in many fields it's far more deductive. Appreciating the difference between and how substance abuse or personality disorder can flavor and cause a patient to appear nearly psychotic or delusional is not something you get by following around a few patients.

That being said you and Claws are both really kind of making out a very perfect non generalizable and non applicable to real world psychiatry. Lots of psychiatrists I've known have missed personality disorders, explained diagnosis in non-dsm fashions, and generally prescribed medications as they felt ex. gabapentin or topamax for bipolar 1. Or worse I've seen doctors add on absurdist regiments at major university centers like, well you're still anxious so buspar, then gabapentin, then topamax. Calling that nuanced isn't correct, it's downright avant garde.

I mean, I pretty clearly spelled out there are a lot of bad prescribers out there. That there are individuals that are bad at what they do within a given field doesn't change the challenging nature of the field itself

 

[clausewitz2]

I can agree with this slightly. My experience on inpatient Sub-Is where I had almost entire autonomy allowed me to really get a solid perspective on the generally inclusive thinking required for diagnosing. This is probably the major difference where as in many fields it's far more deductive. Appreciating the difference between and how substance abuse or personality disorder can flavor and cause a patient to appear nearly psychotic or delusional is not something you get by following around a few patients.

That being said you and Claws are both really kind of making out a very perfect non generalizable and non applicable to real world psychiatry. Lots of psychiatrists I've known have missed personality disorders, explained diagnosis in non-dsm fashions, and generally prescribed medications as they felt ex. gabapentin or topamax for bipolar 1. Or worse I've seen doctors add on absurdist regiments at major university centers like, well you're still anxious so buspar, then gabapentin, then topamax. Calling that nuanced isn't correct, it's downright avant garde.

It makes sense that you have not seen a lot of the nuance if all your rotations were inpatient. In the era of managed care inpatient psychiatry is a very arid, impoverished, barely therapeutic thing most of the time. Crisis management is the name of the game and anything beyond that is sort of dismissed. The real and interesting work is outpatient, getting to know people over time and refine your ideas and formulations longitudinally. I assume I don't have to sell FM folks on the importance of continuity of care.

There are plenty of crappy psychiatrists out there and I'll never disagree with that. This is similar in some sense to the family docs who used to give everyone with back pain Norco back in the day and the ones I see advertising IM B12 and T patches and scheduled IV abx for chronic Lyme in my neck of the woods.

Wrt to some of the medication regimens you highlight I will just say that non-terrible psychiatrists who aren't conducting research most of the time are not thinking all that much in terms of DSM diagnoses, nor indeed were they created to be treated as reified disease processes like might be true of, say, diabetes. That is a much longer and geekier discussion though.

 

[clausewitz2]

Or just told to suck it up.

Everyone who works in mentally health has fantasized about being this guy:



Hectoring anxious people is not as effective in making them less anxious as you might think, shockingly.

You could argue that third-wave therapies like Acceptance and Commitment Therapy and DBT have a strong "suck it up, buttercup" component to them, though. Certainly not treating anxiety as a dangerous thing is part of working in a useful way with anxious people.

 

[Drrrrrr. Celty]

I mean, I pretty clearly spelled out there are a lot of bad prescribers out there. That there are individuals that are bad at what they do within a given field doesn't change the challenging nature of the field itself

They're strangely enough retained faculty at prestigious universities. But it is what it is.

 

[deleted87716]

Everyone who works in mentally health has fantasized about being this guy:



Hectoring anxious people is not as effective in making them less anxious as you might think, shockingly.

You could argue that third-wave therapies like Acceptance and Commitment Therapy and DBT have a strong "suck it up, buttercup" component to them, though. Certainly not treating anxiety as a dangerous thing is part of working in a useful way with anxious people.

That guy is totally me. 😉

 

[Mad Jack]

They're strangely enough retained faculty at prestigious universities. But it is what it is.

Prestige doesn't mean a damn thing, bad prescribing is bad prescribing. If I recommended gabapentin as anything but the last of last resorts for mood stabilization i'm pretty sure my attendings would literally throw me out of the program

 

[clausewitz2]

Prestige doesn't mean a damn thing, bad prescribing is bad prescribing. If I recommended gabapentin as anything but the last of last resorts for mood stabilization i'm pretty sure my attendings would literally throw me out of the program

Pregabalin has very solid data for anxiety and is first line in many countries. There is not a great reason for thinking gabapentin is all that different. I wouldn't use it as a mood stabilizer, but then "mood stabilizer" is a term introduced by Abbott Labs when they decided to repackage valproic acid in the 90s and is not really attested in the psychiatric literature prior to that.

Buspirone is only thought of as an anxiolytic because the company that developed it thought the antidepressant field was too crowded and didn't think it could get enough market share (see also Luvox and OCD). STAR*D showed it is actually pretty effective as antidepressant augmentation when used properly. For the neurasthenic types we are talking about I don't think it's useful to draw a distinction between depression and anxiety so there is nothing crazy about using it. Again, it will never convince anyone that they don't miss their Xanax.

Topamax has mixed evidence for BPD. It probably reduces impulsivity and can certainly introduce a gap between thought and action that is helpful for some people. It also definitely slows down thinking, which ruminators can find very helpful. It is also extremely good at reducing binge drinking in Caucasians who are GRIK1*rs2832407 C- allele homozygotes but the effect vanishes in people who aren't.

Look, it is very possible that the combination you are describing was given by a mouth breather who had no real rationale for what they were doing, and it wouldn't be my first choice of approach, but there are plausible scenarios where it would make sense to do these things. We are getting way into the weeds for an FM forum thread, though.

 

[deleted87716]

Buspar is s__t. "Once they've ridden the BENZ, they won't ride the BUS." True, that.

 

[Mad Jack]

Pregabalin has very solid data for anxiety and is first line in many countries. There is not a great reason for thinking gabapentin is all that different. I wouldn't use it as a mood stabilizer, but then "mood stabilizer" is a term introduced by Abbott Labs when they decided to repackage valproic acid in the 90s and is not really attested in the psychiatric literature prior to that.

Buspirone is only thought of as an anxiolytic because the company that developed it thought the antidepressant field was too crowded and didn't think it could get enough market share (see also Luvox and OCD). STAR*D showed it is actually pretty effective as antidepressant augmentation when used properly. For the neurasthenic types we are talking about I don't think it's useful to draw a distinction between depression and anxiety so there is nothing crazy about using it. Again, it will never convince anyone that they don't miss their Xanax.

Topamax has mixed evidence for BPD. It probably reduces impulsivity and can certainly introduce a gap between thought and action that is helpful for some people. It also definitely slows down thinking, which ruminators can find very helpful. It is also extremely good at reducing binge drinking in Caucasians who are rs2832407 C- allele homozygotes but the effect vanishes in people who aren't.

Look, it is very possible that the combination you are describing was given by a mouth breather who had no real rationale for what they were doing, and it wouldn't be my first choice of approach, but there are plausible scenarios where it would make sense to do these things. We are getting way into the weeds for an FM forum thread, though.

Yeah and it would be more appropriate to call antidepressants anxiolytics, but let's stick to calling the commonly accepted physical objects of a certain shape that are used to dig soil "spades," shall we? Gabapentin for anxiety is one thing, gabapentin for primary mood stabilization I'm a patient with bipolar disorder is an entirely other thing. This is important to the thread, however, that these things are addressed as they are great examples of why psychiatric prescribing might be challenging if you didn't spend four years training in it

 

[deleted87716]

@Mad Jack Two thumbs up for the Latin sig. 👍👍

 

[Drrrrrr. Celty]

Yeah and it would be more appropriate to call antidepressants anxiolytics, but let's stick to calling the commonly accepted physical objects of a certain shape that are used to dig soil "spades," shall we? Gabapentin for anxiety is one thing, gabapentin for primary mood stabilization I'm a patient with bipolar disorder is an entirely other thing. This is important to the thread, however, that these things are addressed as they are great examples of why psychiatric prescribing might be challenging if you didn't spend four years training in it

It may be my generally higher grasp of psych, but I don't think i'm all that sure it takes 4 years to really know much about a lot of these drugs though. Maybe more like a few months and I think SSRIs, SNRIs, Welbutrin, low doses of Abilify/Rexulti, Elavil/Doxepin, Trazedone, short term Benzos, and Buspar and some augmentation are pretty easy to get down. And I think in some respects primary care probably does need to get good at dealing with vanilla psychiatry because otherwise patients are going to be managed by Psych NPs.