IM resident with 2 questions

[CRLD]

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Hello,

I'm an internal medicine resident who has always LOVED psych (to the point I was strongly torn b/w psych and IM - and sometimes wish I'd chosen psych! 🙂) and have continued to and enjoyed studying psychiatry as a resident, with 2 questions.

In terms of background on me, as I said I enjoyed psych as a medical student but entered IM residency at an academic center where nearly all enter fellowship and no one cares at all about psychiatry or primary care medicine. I have in fact recently chosen to do primary care which IMO is a deteriorating and declining area of medicine and a place where a good internal medicine-trained physician can do a lot of good. My clinically-oriented career goal is to be a strong, confident, knowledgeable provider who refers to consultants MINIMALLY - i.e. manages their own heart failure, difficult to control DM, various endocrine d/o's, injects joints, treats some rheumatic illness, etc - of course always with an appropriate understanding of the standard of care and obviously referring when warranted. A natural extension of this, given my enthusiasm for the field of psych is to manage more mental illness than the typical PCP would ever dream of.

I am planning to take a job with a suburban university-affiliated IM practice, 65% privately insured/35% medicare. My questions are these:

1. I have always found it instructive to ask specialists what they feel within their field can be treated by the PCP. In your opinion as psychiatrists what is the spectrum of psychiatric illness a PCP can handle? In terms of depression, obviously per STAR-D after 2-3 failed trials I would refer...but what/when else?

2. Any experience with IM residents doing psych electives or any thoughts on a valuable psych experience a medicine resident could have? Lots of elective time coming up but not sure how to parlay this into a useful psych experience that would be helpful given my career plans - obviously not inpt, probably not C/L psych, maybe setting up some sort of outpt psych experience though not sure how fulfilling this would end up being...

Thanks in advance! Jealous of you guys! 🙂

 

[393656]

Not sure how motivated you are but from the flip side I am a psych resident and in my 4th year of residency approached the IM department asking to start some psych-IM outpatient consulting. I was able to go to the IM resident clinic 2 times per week and see their difficult patients with them, come up with plans, follow up with them and eventually transition back to them. It was a great learning experience for everyone, myself included.

It is highly dependent on the population you see. Here in Ohio the IM clinic sees many uninsured who have no psych access in this city so they were getting very sick patients that were probably more sick than the patients I was seeing in my psych clinic since oddly we do not take uninsured. So YMMV based on population you see.

I am bringing this up because a collaborative relationship will yield you the most one-on one long-term exposure to psychiatry. Now it may be a challenge having a psych person be interested.

So more to the point of what you can do is look into a rotation on the inpatient unit. Unfortunately that is the only place you will probably get to "do" stuff and not just shadow in a clinic. Consult/liason is also a great learning month depending on skills you want to learn. CL is probably not as applicable to outpatient IM practice. Inpatient will get you familiar with plenty of bipolar, severe MDD and psychosis and using the medications necessary. Probably your most high-yield.

If you can forge a better collaberation between the departments than definetly see what you can do.

 

[IAmAUser]

.

 

[nitemagi]

"This hand does not write the word xanax."

I agree it's quite variable. As it being discussed elsewhere (see the psychologist prescribing thread on the psychology forum), a major limitation is that there's no particular requirement for IM's to get any psychiatric training. So it comes down to what a residency included.

Ideally I'd say PCP's could treat
1. anyone stable on their meds for 1+ years could be managed.
2. Basic anxiety or depression

And again for the record, I'd rather have a PCP (physician) prescribing for me than a "medical psychologist."

 

[393656]

"basic anxiety or depression" If it were only that easy I would have no qualms about psychology prescribing. The problem is what people call "depression and anxiety" is often manifestations of multiple other more complicated pictures. Sometimes medical, neurocognitive/degenerative or all too common is missed bipolar disorder. Problem is PCP's and many psychiatrists are absolutely unable to pick up subtle symptoms of bipolarity and fail to get supporting evidence from the patient such as family history, childhood depression or adhd etc etc.

If you could confirm it were simple depression then great but I do not think simple depression exists until after you have it properly diagnosed which I do not feel they can do often. More often than not they do it but only because its the law of numbers that most people will turn out to be regular depression but doesnt mean they "should" be treating these things.

 

[nitemagi]

Agreed, I'm not in favor of psychology prescribing even for "simple" problems. I have less issue with PCP's treating it, though.

Come on over to the psychology prescribing thread if you want to join my rabble-rousing. At this point in their 28 page thread I'm being insulted for being a resident and not having enough training to really contest their experience as psychologists. It's amusing.

 

[OldPsychDoc]

Sorry to give a bit of a non-answer, but it completely depends on the PCP. I've met PCPs who can do a good job with nearly anything in the DSM, and I've met PCPs who I wouldn't trust with adjustment disorder. You have to know yourself, know what you don't know, and refer when your patient would benefit from the referral. Just please don't be one of the PCPs (numerous in my area) who give everyone and their mother loads of Xanax on demand (personal pet peeve) 🙂

You can give MY mom Xanax...

Please!

 

[notdeadyet]

You can give MY mom Xanax...

Please!

Semper Henny Youngman...

 

[whopper]

In your opinion as psychiatrists what is the spectrum of psychiatric illness a PCP can handle?

I generally agree with the statements above.

If a PCP is doing the job well, I would in general only tell PCPs to handle disorders where the GAF has consistently been 61 or above, and there is no history of psychosis or mania.

But like was said above, I wouldn't trust some PCPs to do anything, and I've known some to be truly excellent and even better than some psychiatrists.

I would certainly tell any PCP to think twice or even recommend against treating anything not in the above guidelines and I would even tell that to a heck of a lot of psychiatrists simply doing outpatient practice with no case management and med management often done by a nurse.

I've had a few patients in outpatient private practice where I terminated their care because I could not provide for their needs in the office I worked at. That office is basically on the order of what could be done in a PCP office at best, that is unless you find me a PCP that has case and med management.

E.g. A chronically suicidal borderline PD patient who literally called the office daily for hours a day. I was only int the office 3 days a week during limited hours. No way she was appropriate for the level of care I could provide there.

 

[Manicsleep]

One thing that separates an physician from a mid level sych as a medical psychologist is the ability to understand when to kick it up a notch. Thats not to say that there are PCPs who take care of things they probably shouldn't but, in general they know they are over their heads and will refer a patient out.

"basic anxiety or depression" If it were only that easy I would have no qualms about psychology prescribing. The problem is what people call "depression and anxiety" is often manifestations of multiple other more complicated pictures. Sometimes medical, neurocognitive/degenerative or all too common is missed bipolar disorder. Problem is PCP's and many psychiatrists are absolutely unable to pick up subtle symptoms of bipolarity and fail to get supporting evidence from the patient such as family history, childhood depression or adhd etc etc.

👍

You can teach a monkey to do write a script...you just can't teach it when not to write a script.

 

[393656]

I generally agree with the statements above.

If a PCP is doing the job well, I would in general only tell PCPs to handle disorders where the GAF has consistently been 61 or above, and there is no history of psychosis or mania.

But like was said above, I wouldn't trust some PCPs to do anything, and I've known some to be truly excellent and even better than some psychiatrists.

I would certainly tell any PCP to think twice or even recommend against treating anything not in the above guidelines and I would even tell that to a heck of a lot of psychiatrists simply doing outpatient practice with no case management and med management often done by a nurse.

I've had a few patients in outpatient private practice where I terminated their care because I could not provide for their needs in the office I worked at. That office is basically on the order of what could be done in a PCP office at best, that is unless you find me a PCP that has case and med management.

E.g. A chronically suicidal borderline PD patient who literally called the office daily for hours a day. I was only int the office 3 days a week during limited hours. No way she was appropriate for the level of care I could provide there.

Wow you really use GAF? Let alone expect a PCP to even know what a GAF, forget utilizing it! I have not used it a day in my life. I know only 2 scores. 30 for admitting and 55 for discharge. Really dont think that should be a criteria for a pcp to know when to refer

 

[kugel]

I know only 2 scores. 30 for admitting and 55 for discharge.

RANT ALERT: I am about to climb up on a soapbox.
Wallstreet, I know you were being flippant to make your point about the futility of asking PCP's to utilize GAF scores in deciding whom to refer. (I actually think the GAF comment was meant as short-hand for under what conditions a PCP should try to manage psych problems - not that he thought PCP's would be measuring GAF on patients.)

However, I've seen this protocol taught to students/residents by otherwise intelligent attendings, so I'm going to take a rather extreme tone in my response. Please know I mean no attack on your character. I am responding to the practice of faking GAF scores, and teaching others to do so.
So here goes:

Even if someone is convinced that the current 5-axis diagnostic system is flawed or irrelevant, it is the current standard. Ignoring it is really not an option in most practice situations. Faking a GAF score is really no more ethical than faking an Axis I, II, or III diagnosis - just for the purpose of getting your treatment plan paid for. Why would someone do this? If you don't think the GAF score has meaning, then why document it at all? Why not just leave it off? Oh, yeah...it's required by your system or for payment. So you're willing to fake a diagnosis for payment. But it's okay because You don't think the GAF matters. That's the same argument as, "It's okay to steal from corporations because no one really loses anything." Or, "They charge too much, so it's okay to steal from them."

If a physician is willing to lie on an Axis V diagnosis, why wouldn't (s)he just lie on Axis I? Or about whether a medication was actually given?

Then there's the effect of the lie.
When I read a GAF score, I mistakenly think it was arrived at logically and truthfully. I ascribe meaning to it. I consider that information in my assessment of whether the patient's current functioning is better or worse than when the last doctor saw him.
Your GAF score affects my assessment of the patient.
So, in addition to lying to the payor, you are lying to me - supposedly your colleague.

Yes, I know there are problems with variability and reliability, but that's true of many measurements in medicine. In fact, at least 90% of the time my BP has been measured by hand, it's done so poorly as to be invalid. And I've been given a very powerful anti-HTN medication while semi-conscious in the hospital on the basis of ONE invalid BP measurement. There's variability in measuring cholesterol and LFT's and pressure of a spinal tab. Errors happen when collecting capillary glucose readings and urine specimens for culture. None of that makes it okay to lie and fake a result in the chart.

If you believe GAF scores are irrelevant or invalid, please have the courage to refuse to write them down.

RANT OVER

 

[393656]

Sorry man but I think you misunderstood my post. I do not lie or "make up" GAF scores. I personally believe 30 and below represents the level of functioning that is severely impaired. I believe 50 and above is a high enough functioning person to be on his own with follow-up. Anything above 50 is irrelevent to me clinically and below 30 is irrelevent clinically. 30-50 is the "gray zone."

I am not lying about anything, I simply am choosing to use only 2 GAF scores to indicate the patients level of functioning which IS the point of the system.

By the way I know 100 percent GAF will not exist shortly wiht dsm V as I have spoken to severeal of the editors about this. So will be a moot point.

What clinical benefit is there to giving someone a 60, 75, 80, 82 GAF v. a 50? Does that make you a better clinician or more ethical? I do not get your point

 

[kugel]

Wallstreet, I'm sorry.
My disclaimer at the beginning got lost in the rant.
I really meant nothing toward you.
"However, I've seen this protocol taught to students/residents by otherwise intelligent attendings, so I'm going to take a rather extreme tone in my response. Please know I mean no attack on your character. I am responding to the practice of faking GAF scores, and teaching others to do so. "

I was not directing my rant at you or the details of what you wrote.
I was using your quote simply to bring up the tengentially-related subject of those I know who do lie about the GAF score and who teach others to do the same.

Again, my apologies for making it sound like I was attacking you.
I obviously failed in my attempt at a disclaimer about that.
I knew you were responding to the other post about GAF and you were not saying people should lie on Axis V or anywhere else.

This is one of those subtleties that can be hard to get across in a typed format, as opposed to live. Well, at least it's difficult for me.
'Cause I obviously blew it.

 

[Ibid]

Imo

X axis approach to finding truth: adversarial v inquisitorial
Y axis approach to finding truth: drill down style v pot-holing around the issue
Z axis context dependent factors: eg correlation between internet personality and real life character.

www.whycommunicationontheinternetalwaysendsupinonebigbustup.com

 

[393656]

No offense taken but I was just being clear that personally I do not make it up but I hear you, its largely taught or actually not at all taught. I have not had a SINGLE word in my program about the GAF. I might just be naive about its utility due to my lack of exposure. I agree since it is our current tool in psychiatry so we are stuck with it.

Anyway totally no offense taken but just wanted to make sure it was clear I was not making up the numbers!