If you're incompetent, consider psychiatry. (The Pitt)

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FatherPsychiatry

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SPOILERS about the HBO show "The Pitt".

Synopsis - TV show about a busy ER, with an attending leading a group of residents/med students as they see patients and deal with healthcare systems issues (and actually doing a pretty good job of it IMO).

Anyways, one of the trainees is a PGY3 ER resident who is known to be very slow, sees fewer patients per hour than peers, and spends a lot of time getting to the know patients, validate them etc. The attending criticizes her and gives the line below, which I thought was hilarious.

thoughtpsych.jpg



Do you agree with the absolutely correct assumption the show makes that if you can't see greater than 2 patients an hour in the ER, you should go into psychiatry?

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1) I'd let the EM folks decide if you can't see more than 2 if that is an issue. I'm sure there are CCAH that are okay with a slower pace. Possibly even some urgent care somewhere.

2) If someone is unable to grasp and make headway in their existing specialty, there is also the possibility they might not accel at most every other specialty. The impact of DEI, and simply the failing of academia to fail people means some one could have truly been "passed" along repeatedly because no one wanted the extra headache of making it their problem to speak up this person is lacking. I've had one physician patient once who very well may have been passed repeatedly. And then at the level of attending/job, just couldn't keep up and was losing jobs.

3) Just because a person, in this OP prompt, spends more time talking with patients, validating them, doesn't mean they are meant for psychiatry. Most programs in psychiatry also have time demands and a need to be efficient, which means you can't just chat.

4) A cash DPC or cash psychiatry practice - maybe - might be able to accommodate slower more chit chat, but before you get to do that, you have to be fast and capable with foundational skills [unless in a program that is just passing people along...]
 
A resident being unable to meet the demands of their specialty certainly does not mean on its own that they would do well in psychiatry.

With that said, if someone is really interested in getting to know the human being they are treating including their life circumstances and individual psychology, psychiatry seems like a great fit. Getting to know our patients in the level of detail we do is a lot less available to many specialties.
 
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They probably wouldn't do well in psych. I've known people who couldn't hack it or didn't do well in other specialties like IM, neuro, anesthesia, rads, surgery, and OB/GYN do well in psych. The EM ones often don't work out. There is definitely overlap between psych and EM (you have to be a bit nutty to do either) and some people double apply. I had one student who double applied to EM and psych and ended up in EM. I'm not sure if they were good for EM but they were definitely not great for psych. If someone is a PGY-3 in EM and takes too much time trying to talk with patients, they could be a great fit for palliative medicine.

I offered an emergency psych elective for EM residents. We had 0 takers in 5 years.

Round my way there are several EM docs who now do psych without a psych residency. One did not complete their EM residency either. Some are focused on ketamine but some also do therapy. Again this is without a psych residency (though they have done other trainings/courses).

ETA: I also know of an EM doc who has done quite a lot of research on PTSD. There are some former EM docs who specialize in burnout or offer coaching services (both to physicians and others). Career longevity is hard in EM so it's not surprising that people find other avenues but going into psych residency does not seem common (and I know a lot of people who have moved into psych from other specialties).
 
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I know someone in EM who as an attending did a palliative care fellowship, and somehow was bringing education on that into the EM program.
 
The impact of DEI, and simply the failing of academia to fail people means some one could have truly been "passed" along repeatedly because no one wanted the extra headache of making it their problem to speak up this person is lacking.
lol. Nobody gets exceptions from USMLE 1,2, 3 or board exams which are used to set the minimum academic standards for the practice of medicine. Your claim is outrageously false and misleading.

Getting passed along through undergrad might be one thing, but this does not happen in medicine. You can claim that minorities might not be as highly scoring as their peers, but you cannot say they fail to meet minimum standards which have actually been rising over the years. And overall having diversity in medicine, especially psychiatry, is particularly important for patient care and outcomes.

Rapport is very important in psychiatry, so having people in practice who were less privileged and have more diverse life experiences will allow for more providers whom patients can more readily connect with. This is one reason why it's important to help underprivileged people rise to the occasion. Furthermore, if people feel like there's no opportunity for social mobility it will lead to more issues down the line.

But instead we're using DEI as a scapegoat for why non-minorities have such a hard life. Some of that attention should be turned upward.

Furthermore, what people forget is equity isn't just about race. lol
 
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Getting passed along through undergrad might be one thing, but this does not happen in medicine.
I'm speaking to people of any color, not just URM: Yes, people do get passed along. I think the medical pipeline does a great job of filtering truly outright incompetent (usually incompetent + lazy) people out. At the same time, there's probably a marginal bottom 1-5% (depends on specialty and institution) of people who end up finishing residency where there's debate to be had about whether they should be practicing medicine.

--

As for the OP topic, it's clear in the show that this resident is slow but not incompetent, as the editorialized thread title states. I think it's a fair question as to why someone is in EM when they're spending so much time sitting with one patient, asking to get to know that patient's emotional experience.

Especially when that same attending just supervised like 30 different urgent medical situations in the last 3 hours. (The most unrealistic part of the show is just how many exciting things roll in each hour--on an ostensibly 'normal' day--for just one attending.)
 
I'm speaking to people of any color, not just URM: Yes, people do get passed along. I think the medical pipeline does a great job of filtering truly outright incompetent (usually incompetent + lazy) people out. At the same time, there's probably a marginal bottom 1-5% (depends on specialty and institution) of people who end up finishing residency where there's debate to be had about whether they should be practicing medicine.
"Passed along" can be subjective and ambiguous since most non-academic requirements are. Perhaps we stick to the assertion that people are required to pass the minimum academic standards of USMLE and board exams... it would be eye-opening for me to learn that this is false.
 
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"Passed along" can be subjective and ambiguous. Perhaps we stick to that people are required to pass the minimum academic standards of USMLE and board exams.
It's an accurate statement, although I'd argue passing STEPs+Boards is not inherently reflective of real-world clinical ability, which is what the thread is about. The attending in the OP is not grilling the resident on her in-service exam score. Sushi was talking about people struggling once they're out of residency and practicing medicine independently, not struggling to pass their boards. Clinical evaluations are more subjective and thus easier to "pass people along" out of (positive or negative) bias.
 
I mean clearly the attending should stay out of psychiatry considering he let a kid whose mother stated she found a list of "girls he wanted to hurt at his school" or whatever she said run out of the ER without notifying either the police or the school....then just goes on about his day hoping the kids mom can text him or something lol.

It's not the worst medical drama ever but I think the dumbest part of this show is that I didn't even realize every hour of the show is supposed to be an "hour" in the ER...so like 4 trauma activations every hour haha.
 
It's an accurate statement, although I'd argue passing STEPs+Boards is not inherently reflective of real-world clinical ability, which is what the thread is about. The attending in the OP is not grilling the resident on her in-service exam score. Sushi was talking about people struggling once they're out of residency and practicing medicine independently, not struggling to pass their boards.
Real world clinical ability is difficult to measure objectively. I've known a couple people who were not successful in my old residency program where the culture was to look down on people for DEI reasons (similar to Sushiroll's perspectives) and then they moved to the Northeast into a program that supported them and flourished.
 
"Passed along" can be subjective and ambiguous since most non-academic requirements are. Perhaps we stick to the assertion that people are required to pass the minimum academic standards of USMLE and board exams... it would be eye-opening for me to learn that this is false.

there are plenty of people who fall through the cracks. In my residency program back in the day, the resident a year under me who i was assigned to work closely with was grossly incompetent. Forgot to fill out involuntary hold on a patient and then left, pt was actively suicidal and just walked out the hospital. Another time he saw a psychotic patient in ER, forgot to do orders, so pt sat there overnight without any psych meds. One time he was supposed to order 5mg of zyprexa and ordered 30mg. He made it all the way to third year where they finally kicked him out because he only got worse. Somehow he is practicing though?
 
Real world clinical ability is difficult to measure objectively. I've known a couple people who were not successful in my old residency program where the culture was to look down on people for DEI reasons (similar to Sushiroll's perspectives) and then they moved to the Northeast into a program that supported them and flourished.
there are malignant programs and malignant residents
 
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I mean clearly the attending should stay out of psychiatry considering he let a kid whose mother stated she found a list of "girls he wanted to hurt at his school" or whatever she said run out of the ER without notifying either the police or the school....then just goes on about his day hoping the kids mom can text him or something lol.

It's not the worst medical drama ever but I think the dumbest part of this show is that I didn't even realize every hour of the show is supposed to be an "hour" in the ER...so like 4 trauma activations every hour haha.
I like the show, so far. I think some people seem to feel a little thrown off by how parts of the show are going for "gritty/totally realistic," yet the personalities and pace are caricatured. It's like scrubs turned down a notch into uncanny valley. I also wonder whether laypersons pick up on that about the show (vs "wow doctors are all weird.")
 
lol. Nobody gets exceptions from USMLE 1,2, 3 or board exams which are used to set the minimum academic standards for the practice of medicine. Your claim is outrageously false and misleading.

Getting passed along through undergrad might be one thing, but this does not happen in medicine. You can claim that minorities might not be as highly scoring as their peers, but you cannot say they fail to meet minimum standards which have actually been rising over the years. And overall having diversity in medicine, especially psychiatry, is particularly important for patient care and outcomes.

Rapport is very important in psychiatry, so having people in practice who were less privileged and have more diverse life experiences will allow for more providers whom patients can more readily connect with. This is one reason why it's important to help underprivileged people rise to the occasion. Furthermore, if people feel like there's no opportunity for social mobility it will lead to more issues down the line.

But instead we're using DEI as a scapegoat for why non-minorities have such a hard life. Some of that attention should be turned upward.

Furthermore, what people forget is equity isn't just about race. lol
This liberal trope that matching people's demographics to their treating population is just garbage. It is racist in itself.

The notion that the only way to be culturally competent is to be of that culture - is just flawed. It overlooks the need to broaden one's understanding beyond core life exposures. We don't treat patients in a culture vacuum in most of America, and most of us will treat people who are different.

Chinese only supposed to treat Chinese expats?

Punjabis only supposed to treat Punjabis?

Nigerians only treat Nigerians?

Somalis only treat Somalis?

Anecdote warning - I too used to gobble up this liberal social trope of diversity value - and was talking with a former resident colleague of ethnicity XYZ.
'like wow. you must be highly sought after! you are living in a big pocket of population XYZ and one of the very few XYZ in that area. Well done!'
Person was like no. Just no. Apparently, population XYZ has their own issues about the various types of XYZ and wanted doctors of ABC or EFG or QRS ethnic groups. Took me a bit to wrap my head around this and how it conflicted with the liberal mantra - Diversity! Diversity! Diversity!

But the truth is, DEI is racist. Its garbage. And people want professionals to be that, professionals, and to do their job well, and competently. That's it. Being professional is the warm welcoming, blanket that is the Original Inclusive.

*while in residency I took some people of different ethnic religious groups under my wing to educate on American culture, the US healthcare system, etc. And conversely pressed them to share the details on their culture. Was a good win win. Made for great parties. and great potlucks.
 
The notion that the only way to be culturally competent is to be of that culture - is just flawed. It overlooks the need to broaden one's understanding beyond core life exposures. We don't treat patients in a culture vacuum in most of America, and most of us will treat people who are different.

Chinese only supposed to treat Chinese expats?

Punjabis only supposed to treat Punjabis?

Nigerians only treat Nigerians?

Somalis only treat Somalis?

I agree with you 95%. However, I think there should be some Chinese doctors, some Punjabi doctors, some Nigerian doctors, and some Somali doctors. I think it's important to make sure that their voices have some weight in policy and within the field. Without DEI, certain disadvantaged populations will likely approach 0% representation (hopefully this is hyperbole, but I'm not certain how much). Hard to get a position in a competitive field like medicine (or be interested in it early enough to pivot toward it) when you don't have the right background and societal support early enough in life. These are the populations DEI efforts should be targeting to lift.

Incompetent people should not be doctors, but DEI shouldn't be elevating people without the potential to be competent. It should recognize people with potential who lacked the right support and provide that support for them to be successful. That's what equity is.

Though perhaps we're swaying from the thread topic now. However, I wanted to add that perspective due to the way DEI was brought up. Although if we want to have a thread about DEI being a problem in medicine I'd be happy to discuss.
 
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I mean clearly the attending should stay out of psychiatry considering he let a kid whose mother stated she found a list of "girls he wanted to hurt at his school" or whatever she said run out of the ER without notifying either the police or the school....then just goes on about his day hoping the kids mom can text him or something lol.

It's not the worst medical drama ever but I think the dumbest part of this show is that I didn't even realize every hour of the show is supposed to be an "hour" in the ER...so like 4 trauma activations every hour haha.
LOL I loved that part too. I think even the ER social worker was on the case and sort of just shrugged her shoulders instead of like, calling police or the school to warn them.
 
The notion that the only way to be culturally competent is to be of that culture - is just flawed.[...]
Chinese only supposed to treat Chinese expats?

Punjabis only supposed to treat Punjabis?

Nigerians only treat Nigerians?

Somalis only treat Somalis?
You say "only" several times in there, but that's quite a hyperbolic rephrasing of the DEI concept and the post you quoted. If you are going to exaggerate the claim, then it's not surprising that it's easy to argue against. If you instead address what's actually being posted, then maybe your argument won't be so strong.
 
I really like the show. The statement felt right in terms of how an actual EM attending might conceptualize psychiatry. I don't think the attending was saying psychiatry was easier, but that it was different and might fit her skill set. I do think EM is faster paced than psychiatry, although certainly there are time constraints. Of course, it did not reflect the actual reality of any PGY-3 switching specialties and that grated on me and took me out of the realism. It would have made a lot more sense to say to one of the med students. I like the idea of palliative care both realistically and in terms of the story, but I think it'd be too complicated to explain to civilians.
 
You say "only" several times in there, but that's quite a hyperbolic rephrasing of the DEI concept and the post you quoted. If you are going to exaggerate the claim, then it's not surprising that it's easy to argue against. If you instead address what's actually being posted, then maybe your argument won't be so strong.
Only...
That is the endgame of DEI, and I don't believe that to be an exaggeration, nor hyperbole. That a 1/4 Cherokee, 1/4 Chinese, 1/4 German, 1/4 Irish individual gets treated by a same equivocal ethnic makeup - to do otherwise is a social injustice.

The entire argument and concept of DEI "to be treated by people that look like me" or by people "of same ethnic heritage" is completely racist. So, so fundamentally flawed, and surprising it has taken this many years to get to our current political dismantling.

It implies that some how, a 2nd generation Mauritian can't understand or treat a 3rd generation Vietnamese, nor a 6th generation Scots/Irish.

DEI = Racism

As far as why I mentioned DEI as being connected to the issue of academia and its passing people through, I don't know if me attempting to articulate it in a more in depth treatise would elucidate for many. I think this may be too much of a politicized topic to see beyond one's blinders for some for how they are connected, mildly, but still connected.
 
Only...
That is the endgame of DEI, and I don't believe that to be an exaggeration, nor hyperbole. That a 1/4 Cherokee, 1/4 Chinese, 1/4 German, 1/4 Irish individual gets treated by a same equivocal ethnic makeup - to do otherwise is a social injustice.

The entire argument and concept of DEI "to be treated by people that look like me" or by people "of same ethnic heritage" is completely racist. So, so fundamentally flawed, and surprising it has taken this many years to get to our current political dismantling.

It implies that some how, a 2nd generation Mauritian can't understand or treat a 3rd generation Vietnamese, nor a 6th generation Scots/Irish.

DEI = Racism

As far as why I mentioned DEI as being connected to the issue of academia and its passing people through, I don't know if me attempting to articulate it in a more in depth treatise would elucidate for many. I think this may be too much of a politicized topic to see beyond one's blinders for some for how they are connected, mildly, but still connected.
There are pretty even-handed takes on the subject that earned dramatic political backlash before the "culture wars" that turned the subject into hyperbole really took hold. Dr. Wang paid the price for it: https://www.ahajournals.org/doi/pdf/10.1161/JAHA.120.015959
 
I saw this real-time and thought it sounded shady but I get what he was saying. However psych isn't something you can just drop out of and pick up easily so rightfully so the next statement from the resident was "I don't want to do psychiatry. I want to be here" or something like that.
 
To me it seemed like she prefers more time and more in depth connection with patients, which is not reality in emergency medicine, but is doable in psych.
 
To me it seemed like she prefers more time and more in depth connection with patients, which is not reality in emergency medicine, but is doable in psych.
Yes, although I think even in a psych rotation, the supervisor would be questioning just “hanging out” with the patient and her wife as being an efficient use of valuable resources. Maybe go talk to the kraken a bit more. It would be nice to have a psychiatrist on this show as my experience in the ED is that there is lots and lots of work to do and it could be helpful to show some more of that from a more genuine perspective. All in all, I like the show but then again I was a big ER fan so seeing Dr. John Carter back in action is nostalgic fun for me and as a similar aged guy with similar personality style, I relate. I used to be the eager young student way back when and now I’m kind of the grizzled veteran who is a bit harsh but still has some skills. At least that’s what I like to think. 😁
 
It's really rare for acute psychiatry focused medical tv dramas to work out. I can only think of one that even made it to series, Mental, and that was rapidly cancelled. People seem to view acute psychiatry as a sort of background element mostly, unless it's somehow forensically focused. Yet we get 20 years of an inpatient surgery drama...
 
It's really rare for acute psychiatry focused medical tv dramas to work out. I can only think of one that even made it to series, Mental, and that was rapidly cancelled. People seem to view acute psychiatry as a sort of background element mostly, unless it's somehow forensically focused. Yet we get 20 years of an inpatient surgery drama...
A little too real for people. Having surgeons treat everything including psych stuff and never even talk to any other doctors at the hospital is much more palatable apparently. I would just like to have an actual psychiatrist character in the show. Showing how doctors deal with scope of practice and collaborate a bit could actually be interesting. In Pitt, I think the surgeon was in there trying to give everyone a tracheotomy and saying let the real doctors work. Also, the issue with beds is pretty real too. So far, I am loving the show.
 
A little too real for people. Having surgeons treat everything including psych stuff and never even talk to any other doctors at the hospital is much more palatable apparently. I would just like to have an actual psychiatrist character in the show. Showing how doctors deal with scope of practice and collaborate a bit could actually be interesting. In Pitt, I think the surgeon was in there trying to give everyone a tracheotomy and saying let the real doctors work. Also, the issue with beds is pretty real too. So far, I am loving the show.
I think ED psychiatry would work in a way that outpatient or inpatient psych wouldn't. There's a lot of elements/situations that would lend themselves to the drama, ranging from "psych" presentations and their diagnoses ("they aren't crazy...they have a prion disease"*), malingering, the realities of involuntary treatment (e.g. intern's emotional reactions to seeing physical/chemical restraint for the first time), or the weirdness of the legal facets of ED psych ("it's a really bad idea to let them go, but they don't meet retention criteria, so we can't stop them")

*Based on a true story
 
I think ED psychiatry would work in a way that outpatient or inpatient psych wouldn't. There's a lot of elements/situations that would lend themselves to the drama, ranging from "psych" presentations and their diagnoses ("they aren't crazy...they have a prion disease"*), malingering, the realities of involuntary treatment (e.g. intern's emotional reactions to seeing physical/chemical restraint for the first time), or the weirdness of the legal facets of ED psych ("it's a really bad idea to let them go, but they don't meet retention criteria, so we can't stop them")

*Based on a true story
My true story was the opposite, not a prion disease but severe depression leading to a pseudo dementia. Can make for some good tv. I think one problem with the psych stuff though is it doesn’t resolve quickly so that makes it tough for a show like this.
 
My true story was the opposite, not a prion disease but severe depression leading to a pseudo dementia. Can make for some good tv. I think one problem with the psych stuff though is it doesn’t resolve quickly so that makes it tough for a show like this.
Ding ding ding! There's the answer. You could get a couple of cool episodes with psych stuff, but unless it's a forensically focused show with a lot of drama mixed in there are very few things in psych where we are going to be able to rapidly stabilize or "fix" someone like surgery and ER does. It's why even most medical shows focus a lot of drama and the actual medical aspects are just secondary. Reality is too slow/depressing, people don't want to watch that.

Only exception I can think of is the HBO show "In Treatment" that followed a set of patients through psychotherapy with the psychiatrist being the connecting point. Even that still had quite a bit of drama and crossed boundaries, but at least had some accuracy as well from my understanding. I never watched it fully, but in residency our psychodynamic supervisor used clips from the show to highlight certain techniques and principles during didactics. Seemed fairly interesting at least.
 
Yes, In Treatment was excellent, including the reboot, but definitely had more of a focus on chronic issues.
 
Yes, In Treatment was excellent, including the reboot, but definitely had more of a focus on chronic issues.
I've meant to check it out for years but most of the time when I get home the last thing I want to do is be thinking about therapy, lol.
 
Honestly, a highlight of the show regarding psychiatry was the turkey sandwich guy. He was a perfect description of the guys I would see in the ED.
 
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