How to maximize psych training in FM?

[Atlas Shrugged]

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.

Agreed. Routine anxiety, depression, and substance abuse should be the domain of family medicine. Things we are likely unable to handle alone: borderline (don't have the time), bipolar, conduct, schizophrenia, conversion/somatiform/whatever the new word is, and other severe mental illness. I would be comfortable continuing to see such patients after expert psychiatric advice, but I would want input and recommendations in how to help them.

The 45 year old woman who is feeling a little down doesn't necessarily need to see a psychiatrist.

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[Drrrrrr. Celty]

Agreed. Routine anxiety, depression, and substance abuse should be the domain of family medicine. Things we are likely unable to handle alone: borderline (don't have the time), bipolar, conduct, schizophrenia, conversion/somatiform/whatever the new word is, and other severe mental illness. I would be comfortable continuing to see such patients after expert psychiatric advice, but I would want input and recommendations in how to help them.

The 45 year old woman who is feeling a little down doesn't necessarily need to see a psychiatrist.

I think even moderate to severe anxiety and depression and vanilla bipolar can be managed by FM/PC. Likewise I fully believe in expanding mental health fellowships to allow FM to handle full fat psychosis, refractory depression, etc.

This not to acknowledge that many rural FM programs are already basically preparing their residents and handling a lot of more advanced and severe psych patients.

 

[VA Hopeful Dr]

I think even moderate to severe anxiety and depression and vanilla bipolar can be managed by FM/PC. Likewise I fully believe in expanding mental health fellowships to allow FM to handle full fat psychosis, refractory depression, etc.

This not to acknowledge that many rural FM programs are already basically preparing their residents and handling a lot of more advanced and severe psych patients.

Can but most of us shouldn't.

 

[deleted87716]

...full fat psychosis...

Is this a new term for being crazy fat...?

 

[Sardonix]

Is this a new term for being crazy fat...?

I believe it's a new slang term the kids use to describe the "cool" kind of psychotic breakdown. I've only seen it spelled "phull phat psychosis" though.

 

[clausewitz2]

I think even moderate to severe anxiety and depression and vanilla bipolar can be managed by FM/PC. Likewise I fully believe in expanding mental health fellowships to allow FM to handle full fat psychosis, refractory depression, etc.

This not to acknowledge that many rural FM programs are already basically preparing their residents and handling a lot of more advanced and severe psych patients.

Depending on the study 50-80% of folks with persistent depression meet criteria for a personality disorder. Sure you could do intensive psychotherapy with them but a) you need dozens-hundreds of hours of supervision to do this well and b)in what sense are you acting as a family doc?

Russ Harris certainly went from being a family doc to being a very well known and successful therapist but I don't think he's doing much managing of HTN/DM/CHF/COPD these days.

 

[clausewitz2]

Agreed. Routine anxiety, depression, and substance abuse should be the domain of family medicine. Things we are likely unable to handle alone: borderline (don't have the time), bipolar, conduct, schizophrenia, conversion/somatiform/whatever the new word is, and other severe mental illness. I would be comfortable continuing to see such patients after expert psychiatric advice, but I would want input and recommendations in how to help them.

The 45 year old woman who is feeling a little down doesn't necessarily need to see a psychiatrist.

This is a good list. I would add eating disorders as a place where a good family doc collaborating with trained therapists in a place where there aren't a lot of specialists might have a really useful role but it is a pretty time intensive thing.

 

[Drrrrrr. Celty]

Depending on the study 50-80% of folks with persistent depression meet criteria for a personality disorder. Sure you could do intensive psychotherapy with them but a) you need dozens-hundreds of hours of supervision to do this well and b)in what sense are you acting as a family doc?

Russ Harris certainly went from being a family doc to being a very well known and successful therapist but I don't think he's doing much managing of HTN/DM/CHF/COPD these days.

What % of psychiatrists are doing intensive psychotherapy? Likewise shouldn't that be job of psychologists who are trained for years in therapy as opposed to a year in psych residency.

 

[clausewitz2]

What % of psychiatrists are doing intensive psychotherapy? Likewise shouldn't that be job of psychologists who are trained for years in therapy as opposed to a year in psych residency.

It's pretty close to the number of psychiatrists who are effectively treating personality disorder. Depending on the region, between 0 and a significant percent.

I mean if we are talking about throwing random drugs at someone that don't accomplish much I can treat lung cancer no problem.

My point is with the time constraints of a typical FM appointment you cannot do very much about personality disorders, and that is often a huge part of the picture of persistent depression. A good psychiatrist not interested in doing therapy would know how to assess this. You cannot do this in a 10-15 minute appointment.

 

[Keona]

I have had a few patients who flat out refused all therapists. We did 15 min sessions of me doing the best that I could while trying to help. I was so emotionally exhausted after each one because they also wanted to do my back hurts, etc during visits and I’ve got minimal training in therapy. One was actively suicidal and I finally got him hooked into real psychiatric support (severe ptsd from a war) but he still wanted to come talk to me too since I’d been through it with him and he trusted me.

 

[clausewitz2]

I have had a few patients who flat out refused all therapists. We did 15 min sessions of me doing the best that I could while trying to help. I was so emotionally exhausted after each one because they also wanted to do my back hurts, etc during visits and I’ve got minimal training in therapy. One was actively suicidal and I finally got him hooked into real psychiatric support (severe ptsd from a war) but he still wanted to come talk to me too since I’d been through it with him and he trusted me.

There's a reason most therapists consider 25-30 patient contact hours per week a full time gig.

 

[hallowmann]

This thread has gone way off track with all this talk, so I'm going to try to reel it in.

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?

FM-Psych don't always end up just doing psych. I actually know plenty that are actually doing combined work at FQHCs, addiction treatment centers, integrative care, behavioral health at FM residencies staffing both behavioral health and FM clinic, etc. Even the ones that do "only" psychiatry tend to, by virtue of having the training, inform/help the significant medical comorbidities their often disconnected patients have. They also attract the medically sicker patients. I would also argue that FM and Psych are actually uniquely suited to be combined in training, because of the high volume of primary psych pts family docs see and treat, and the significant impact lack of good primary care has on psychiatric health. You can learn more about combined training at the AMP conference in ATL in Oct if you want. Anyway, rant for combined training over.

There are actually a lot of paths you can take. FM + Addiction fellowship or behavioral health fellowship, Psych + Addiction, Primary Care, or CL fellowship, etc. A lot of people in FM (and most fields) have an area they enjoy more and become "the" person to ask or refer to regarding those issues.

If you're looking for FM programs that have a heavy psych component, I would look into programs that have a curriculum that incorporates/emphasizes psychosocial medicine (like the P2 program at the University of Rochester). A lot of programs also incorporate addiction medicine and you can get MAT training during FM residency. You can also look into FM programs that have a behavioral health track.

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...

The main point of family medicine is to train general family docs broadly, training them to subspecialize isn't necessarily the point. A lot of programs incorporate tracks without necessarily devoting 6 mos, and people do pretty well with them.

I believe it's a new slang term the kids use to describe the "cool" kind of psychotic breakdown. I've only seen it spelled "phull phat psychosis" though.

P3 for short

 

[deleted87716]

P3 for short

So, basically the same as max RPM?*

*R. P. McMurphy

 

[betamale]

This thread has gone way off track with all this talk, so I'm going to try to reel it in.



FM-Psych don't always end up just doing psych. I actually know plenty that are actually doing combined work at FQHCs, addiction treatment centers, integrative care, behavioral health at FM residencies staffing both behavioral health and FM clinic, etc. Even the ones that do "only" psychiatry tend to, by virtue of having the training, inform/help the significant medical comorbidities their often disconnected patients have. They also attract the medically sicker patients. I would also argue that FM and Psych are actually uniquely suited to be combined in training, because of the high volume of primary psych pts family docs see and treat, and the significant impact lack of good primary care has on psychiatric health. You can learn more about combined training at the AMP conference in ATL in Oct if you want. Anyway, rant for combined training over.

There are actually a lot of paths you can take. FM + Addiction fellowship or behavioral health fellowship, Psych + Addiction, Primary Care, or CL fellowship, etc. A lot of people in FM (and most fields) have an area they enjoy more and become "the" person to ask or refer to regarding those issues.

If you're looking for FM programs that have a heavy psych component, I would look into programs that have a curriculum that incorporates/emphasizes psychosocial medicine (like the P2 program at the University of Rochester). A lot of programs also incorporate addiction medicine and you can get MAT training during FM residency. You can also look into FM programs that have a behavioral health track.



The main point of family medicine is to train general family docs broadly, training them to subspecialize isn't necessarily the point. A lot of programs incorporate tracks without necessarily devoting 6 mos, and people do pretty well with them.



P3 for short

Then we (OB, Sports, Geri, EM... fellowship trained FPs) must be saddest group of GPs out there...our fellowship training have zero value

 

[hallowmann]

Then we (OB, Sports, Geri, EM... fellowship trained FPs) must be saddest group of GPs out there...our fellowship training have zero value

Except training to subspecialize is exactly the point of fellowships... its just not the point of FM residency.

You went to get extra training to better serve your patients in an area you're passionate about. My comment was regarding your assertion that every FM residency should devote 6 mos out of the short 3 yrs solely to one subspecialty. They shouldn't. That's what fellowships and electives are for.