Is it true that psychiatrists...

[Symmetry11]

Lose their medical knowledge throughout years of practicing psychiatry? I mean do psychiatrists feel comfortable in handling a patient that might present with a medical and mental illness? I ask this question because I want to have a comfortable life and work with under served populations who will most likely present with co-occurring medical illnesses who will probably not have the resources to go from doctor to doctor. My solution to this problem is to consider a combined IM/Psych or FM/Psych residency to better adapt to a patients needs. How competitive are these programs? And what would a workday be like for someone dual certified? Are they primarily psychiatrists who can also manage medical issues well or vice versa?

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[masterofmonkeys]

1) I kind of wish I'd done an FM/Psych residency, but my understanding is that almost all dual boarded docs end up doing one or the other. Of course, if you do primary care afterward that still means 30% of what hits your door in outpatient will be psych. I've heard that at least a few of the dual-boarded docs will do mostly primary care but also take on a limited therapy load, things like that. In other words, not sure how well it works in the real world to be a 'dual threat'.

2) As a psychiatrist, by the time you finish intern year, you will have something between 2 and 3x the preclinical education of a mid-level and 5-10x the clinical hours in general medical training of a mid-level. To me this says you are adequately trained to deliver at least basic primary care, just as a mid-level would be. Now the problem is finding a place that won't wig out about it. Last year I trained at a CMHC where getting patient's into primary care for logisical as well as psych reasons could be difficult. They didn't mind me doing some elementary stuff with metformin, anti-hypertensives, abx, asthma meds. This year I'm in a different location and, well, they care, a lot. Like renew asthma meds is a problem. Most malpractice insurances consider a certain portion of primary care to be acceptable even within psych so THEY don't have a problem with it as long as it's reasonable.

3) You lose what you don't use. If you read and do CMEs in primary care there's no reason to think that the knowledge will suddenly disappear. We have like 6 diseases and 5 drugs in psych. There's plenty of time to keep up on basic elements of primary care. If you DO do some primary care, be able to identify and keep around some people who you can consult with regularly. I have EM and IM docs I speak to on a regular basis (mostly because they're my mother and gf lol!).

In other words, it's a culture issue and not a pragmatic issue.

 

[keifernny2]

I could never fit this level of care (in addition to psychiatric care) into a 30 minute visit, probably because I don't do it every day.

I also don't generally have time or facilities in a CMHC to do a proper physical exam that would constitute standard of care for diagnosing/treating at a primary care visit.

Most dual boarded psychiatrists I've seen either specialize in one or the other specialty, work in the VA where the liability is lower and the patient will have another PCP assigned, or pick a 3rd specialty like pain management or pall med that encompasses some of both.

The way the programs work, you spend an extra 1 year in residency total (losing $200k in income for that year), and generally split your time 50/50 between each program., changing back and forth every 3-6 months. The shortening all happens in electives. So, ultimately, you're an Intern for 2 years, which can be tough for some people to handle. Once you finish and become board certified, you'll have to pay for 2 Board Cert Exams, and complete CME and MOC for 2 different specialty boards. You will see patients and receive the same reimbursement for an E/M code as if you'd just done one specialty.

If you are treating more problems at each visit, I suppose you could justifiably bill more patients at a high level E/M code than otherwise. Most Psychiatrists I know bill at the higher level codes anyway, so I'm not sure how much additional reimbursement you'd actually get.

 

[clausewitz2]

In other words, it's a culture issue and not a pragmatic issue.

So much this. I worked with one psychiatrist at a CMHC with a culture like the second location you describe who actually refused to order a TB test for someone. Not evaluate him for TB, mind, he just needed the test to secure some assisted housing his case manager had lined up. But no, wouldn't order the test, because "that's medical"

For all that I appreciate people talking about how you are doing no one a service by acting as a half-assed internist, I never wanna be that guy.

 

[Bartelby]

As a graduating psychiatry PGY-IV I am not currently competent to practice as a primary care physician. I would argue that I didn't "lose it" as, in my opinion, no graduating medical student is competent to do so until they have completed residency training. It's the experience rather than the booklearning that makes the difference, I think.

Keep in mind that if you want to work with the underserved there is way more than enough psychopathology to occupy your time. There is no shame in working as a team with a primary care physician to provide the best care possible with the resources available. I think that is better than trying to keep up with everything in both fields (which is a tall order and to do so competently would probably make your life quite difficult). We all want to do what's best for our patients, but sometimes that means allowing others with more/different expertise to step into their care as well.

 

[Bartelby]

And I should add: do I think I could manage BPs and lipids, or tweak someone's asthma regimen, or adjust their coumadin? Sure. But what about working up potential pneumonia, exploring abnormal LFTs, addressing vague abdominal pain, managing an unidentified rash, putting in sutures, etc? There is just so much that primary care doctors do that I feel like my patients would not get the care they deserve without a PCP on their team.

 

[Shikima]

Being dual specialities, I have a different perspective. One is psych the other is a form of "physical" medicine.

If you want FP/IM and Psych. Go ahead. The business model which uses both, IMO, is that you'll have a FP clinic and you'll be able to accurately prescribe psychotropics. You may want to keep the people in your practice to generate revenue, as it is becoming more consistent that Psych income generation is an numbers game through 15 min appointments. You can allocate more time on your schedule for the initial interview which would include looking at all other physical medicine problems at the same time. In essence, more comprehensive which allows you to bill at a higher billing level. This translates into more reimbursement out of complexity.

Additionally, if they are too complicated and/or just out of the hospital, you'll be able to manage them until they're attached to a more comprehensive mental health clinic which has case managers and the likes. In short, you can cherry pick the easy ones and send the more complicated ones on who need additional services which you cannot provide. Also, you'll be able to sign off on sick leave paperwork more easily.

I'd say go for it and be sure you're in a large primary care practice where your colleagues can also refer to you too - this keeps the revenue within the clinic and all benefit from this arrangement. Be sure, when you're developing contracts, that your contract specifies a collaborative arrangement, not just a dumping ground. And if you want to do suboxone, be ready for the addiction clientele, which may or may not be worth it. You may just want to send addictions out. Your choice on this one.

 

[Symmetry11]

Could a CL fellowship satisfy this need I have to know about medical issues as well?

 

[hamstergang]

Could a CL fellowship satisfy this need I have to know about medical issues as well?

Sort of. But you aren't even applied to medical school yet, right? You are very much jumping the gun. For one thing, you don't know what the political landscape of medicine will be like by the time you get out. For another, as you actually get to practice in various settings, you will see what it is that you actually enjoy doing and want to do. You don't need all the details now.

By the way, this is the answer as far as I see it:

I would argue that I didn't "lose it" as, in my opinion, no graduating medical student is competent to do so until they have completed residency training. It's the experience rather than the booklearning that makes the difference, I think.

...I think that is better than trying to keep up with everything in both fields (which is a tall order and to do so competently would probably make your life quite difficult). We all want to do what's best for our patients, but sometimes that means allowing others with more/different expertise to step into their care as well.

 

[notdeadyet]

Could a CL fellowship satisfy this need I have to know about medical issues as well?

No. A C/L fellowship is helpful to providing consulting psychiatric services to patients whose medical needs are being cared for by another physical medicine provider.

If you want to practice medicine outside of your specialty (whether it's Peds, or Family, or IM), you need to do that specialty. There are combined residencies, with their inherent drawbacks that folks above have described well.

If you are truly interested in providing care to the underserved, you will likely quickly find that medically underserved communities tend to be underserved for their mental health needs as much or more than their physical health needs. Provide services to the population you have the training in.

 

[PikminOC]

I continue cme IM. I completed a categorical first year IM position and took the practice abim exams.

Like anything else it depends on the person.

I disagree with the midlevel comparisons. Our educations and step 123 are far beyond their educations.

 

[birchswing]

The question I always wonder about is whether a psychiatrist would stand up on a plane when they ask if there are physicians onboard. It's possible they would ask for a behavioral issue. I've heard some planes (but not all) have injectable sedatives onboard. But what if a person were choking, having an allergic reaction, having a heart attack, etc? Would you remember enough from medical school to do an emergency tracheotomy for example (I think that one comes to mind because it's in a lot of TV shows and movies)?

 

[Armadillos]

Could a CL fellowship satisfy this need I have to know about medical issues as well?

Honestly most CL folks do less knitty gritty day to day medicine than most inpatient psych attendings seeing as they aren't the primary physician caring for their patients during the hospitalization.

 

[Bartelby]

The question I always wonder about is whether a psychiatrist would stand up on a plane when they ask if there are physicians onboard. It's possible they would ask for a behavioral issue. I've heard some planes (but not all) have injectable sedatives onboard. But what if a person were choking, having an allergic reaction, having a heart attack, etc? Would you remember enough from medical school to do an emergency tracheotomy for example (I think that one comes to mind because it's in a lot of TV shows and movies)?

Surprisingly I saw an article on this some time back. The answer is that yes, psychiatrists should stand up and volunteer. We know way more than a lay person would about any potential medical emergency, and there are actually physicians who can talk us through the emergency available by radio. It's much easier for them to at least have someone who speaks the language to instruct.

 

[Armadillos]

The question I always wonder about is whether a psychiatrist would stand up on a plane when they ask if there are physicians onboard. It's possible they would ask for a behavioral issue. I've heard some planes (but not all) have injectable sedatives onboard. But what if a person were choking, having an allergic reaction, having a heart attack, etc? Would you remember enough from medical school to do an emergency tracheotomy for example (I think that one comes to mind because it's in a lot of TV shows and movies)?

I would not jump up on the first call. If nobody else were volunteering then I would definitely help. Nowadays companies contract with docs on the ground to do essentially telemedicine via plane radio, so I would easily be able to have a medical conversation with them about what was going on and use their medical decision making. Would count on there being a nurse or EMT for doing any procedures.

 

[hamstergang]

The question I always wonder about is whether a psychiatrist would stand up on a plane when they ask if there are physicians onboard.

Yes, psychiatrists are physicians so why would we not? We're better than nothing. Plus, most emergency medical issues on planes are easy: figure out what goodies the plane has that's usable (probably not much), and then land the plane. Unless it's not a real emergency, in which case keep the plane flying and yell at the person for making you get up. Or so it goes in my head.

 

[FlowRate]

Yes, psychiatrists are physicians so why would we not? We're better than nothing. Plus, most emergency medical issues on planes are easy: figure out what goodies the plane has that's usable (probably not much), and then land the plane. Unless it's not a real emergency, in which case keep the plane flying and yell at the person for making you get up. Or so it goes in my head.

Here's a great article in NEJM about airline medical emergencies. I read it when it came out (but didn't just now). IIRC, the pilot/ground medical crew makes the determination on whether or not to land, with your input.

 

[Leo Aquarius]

To the OP, go into Psychiatry and then do Pain Medicine. It will demand daily neuro and PM&R exams, a mastery of anatomy, deep medical knowledge, and even radiological reading skills of live fluoroscopy, plain films, ultrasound, CTs, and MRIs. It's what I'm doing and I love it.

I really missed medical knowledge during residency and found a niche that excited me. Just wanted to throw this out there as another approach.

 

[FlowRate]

To the OP, go into Psychiatry and then do Pain Medicine. It will demand daily neuro and PM&R exams, a mastery of anatomy, deep medical knowledge, and even radiological reading skills of live fluoroscopy, plain films, ultrasound, CTs, and MRIs. It's what I'm doing and I love it.

I really missed medical knowledge during residency and found a niche that excited me. Just wanted to throw this out there an another approach.

Just to add to this for OP; I believe psychiatrists can also do headache fellowships. (and sleep med, which is more commonly known) Both of those include neuro/physical exams and even some procedures for those who get trained in headache (blocks, trigger, botox).

 

[Armadillos]

To the OP, go into Psychiatry and then do Pain Medicine. It will demand daily neuro and PM&R exams, a mastery of anatomy, deep medical knowledge, and even radiological reading skills of live fluoroscopy, plain films, ultrasound, CTs, and MRIs. It's what I'm doing and I love it.

I really missed medical knowledge during residency and found a niche that excited me. Just wanted to throw this out there an another approach.

I know there are pain programs out there that like to have psych trained fellows, but practically speaking how do pain fellows who came from psych adjust into fellowship seeing as we have literally no procedural training? Do they supervise the fellows differently?

 

[Leo Aquarius]

Much steeper learning curve at first. They have to hand hold us for the first month of procedures. But we handle the patient-physician relationships like none other. After month 6 you can't tell the Gas trained from the Psych trained procedurally. But its competitive, and you gotta be a competitive applicant.

 

[notdeadyet]

The question I always wonder about is whether a psychiatrist would stand up on a plane when they ask if there are physicians onboard.

They would. I have. I am not going to be able to find a central line as well as my internal medicine cadre, but I can still do ACLS and practice basic medicine, especially with remote support.

 

[notdeadyet]

If you're looking for fellowships to scratch your medicine itch, consider palliative care and hospice medicine. Strong psych component but LOTS of medical issues and it's a field in which psychiatry is seen more as an asset in many programs than in a lot of fellowships in which psychiatrists seem to be grudgingly allowed.

 

[Symmetry11]

To the OP, go into Psychiatry and then do Pain Medicine. It will demand daily neuro and PM&R exams, a mastery of anatomy, deep medical knowledge, and even radiological reading skills of live fluoroscopy, plain films, ultrasound, CTs, and MRIs. It's what I'm doing and I love it.

I really missed medical knowledge during residency and found a niche that excited me. Just wanted to throw this out there as another approach.

This is exactly what I am looking for! But what does a psychiatric perspective bring to pain medicine? How do they incorporate their training?

Also, would I be able to practice general psychiatry at a CMHC or PP while acting as a pain doc?

 

[smalltownpsych]

This is exactly what I am looking for! But what does a psychiatric perspective bring to pain medicine? How do they incorporate their training?

Also, would I be able to practice general psychiatry at a CMHC or PP while acting as a pain doc?

Chronic pain and depression interact with each other. Pain makes you have depressed mood, and depression increases sensation of pain. Also, opiates alleviate pain and depressed mood, but then make both worse. Most interestingly though are the various pathological personality structures that chronic pain sufferers may have.

 

[Symmetry11]

Is there a job market for pain psychiatrists?

 

[Leo Aquarius]

Is there a job market for pain psychiatrists?

We are unicorns... nobody's ever seen us. Hospitals don't know we exist. Most doctors don't know we exist. There's no job market because there's no precedent. You won't find any jobs looking for a Psych trained Pain doctor. I'm going to have to carve my own job market.

If you want to do Pain, you're much better off doing Gas or PM&R first. For me it was a discovery during residency.

 

[Symmetry11]

How will you do that? Are you not employable at a pain clinic even after a pain fellowship?


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[Leo Aquarius]

How will you do that? Are you not employable at a pain clinic even after a pain fellowship?


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Look for my private message

 

[Bartelby]

This is exactly what I am looking for! But what does a psychiatric perspective bring to pain medicine? How do they incorporate their training?

Also, would I be able to practice general psychiatry at a CMHC or PP while acting as a pain doc?

My impression is that pain from psych is very competitive, so if interested talk to people like Leo early to know what it would take to match.

 

[erg923]

This is exactly what I am looking for! But what does a psychiatric perspective bring to pain medicine? How do they incorporate their training?

Also, would I be able to practice general psychiatry at a CMHC or PP while acting as a pain doc?

Pain is not merely medicated by physical factors, as I'm sure you are aware.

 

[notdeadyet]

Pain is not merely medicated by physical factors, as I'm sure you are aware.

Yes, but no one really refers patients to pain specialists to treat their non-physical factors. His/her question is valid.

 

[erg923]

Yes, but no one really refers patients to pain specialists to treat their non-physical factors. His/her question is valid.

She asked about the perspective a mental health specialist could bring to pain medicine. And I would assert that they are very relevant and useful because pain is not merely mediated/influenced by physical factors.

And pain medicine practitioners are well aware of this fact, as are psychiatrists.

 

[milesed]

I don't feel as if I've lost too much of what I learned in med school and residency. If you do any inpt work, you will continue to use a lot of the IM you learned. I now only do outpt work but am surprised by how much I remember as patients talk about their medical problems. I don't treat the medical problems as I think I would be asking for a malpractice suit.

Would I stand up on a plane if they asked for a doctor? Absolutely. I may not save them, but I'd certainly try. In residency a supervisor told us that we are..
1. Human
2. Medical Doctors
3. Psychiatrists

 

[michaelrack]

Yes, but no one really refers patients to pain specialists to treat their non-physical factors. His/her question is valid.

There are a lot of referrals to pain specialists for non-physical factors- however most pain specialists don't treat the non-physical factors (in my neck of the woods)

 

[masterofmonkeys]

I continue cme IM. I completed a categorical first year IM position and took the practice abim exams.

Like anything else it depends on the person.

I disagree with the midlevel comparisons. Our educations and step 123 are far beyond their educations.

Uh, that was my point. We have FAR MORE than a mid-level level of training, so I think it's ok to act like one so long as we continue CME and have a reasonable access to supervision.

This is also why I disagree with Bartleby, we do have far more than a mid-level training and acting like we have none simply because we're not BE in primary care makes no sense. So long as we are not representing ourselves as or acting as fully-fledged PCPs, I don't see the problem.

I'm not an internist and don't behave like one, but I'm also not scared to do something if (for instance) a patient doesn't have a PCP for INTERIM care, or to add a 2nd hypertensive if I can't convince my pt to GO to their PCP (which happened all the time at the CMHC I trained at), or order appropriate tests so the speialist I referred to actually has something to look at. At the safety net hospital I worked at, due to the way state grants worked, it wasn't unheard of to qualify for free psych visits, free labs, free meds (I mean "free"), but NOT qualify for PCP visits. So I was just supposed to ignore the COPD, appropriate need for pneumovax, TSH in the 5s, or mild DM2? That's a good way to get my butt sued for negligence. If I were a defense lawyer I'd be all over it.

 

[notdeadyet]

Uh, that was my point. We have FAR MORE than a mid-level level of training, so I think it's ok to act like one so long as we continue CME and have a reasonable access to supervision.

How much our training exceeds NPs/PAs isn't as relevant as folks make it. Because most of our training occurs at the medical school level and involves things we wouldn't even consider doing as a psychiatrist. I did a bunch of rotations in trauma surgery, pediatrics, pathology, and a bunch of classes in histology and biochemistry, but you won't see me using any of that on the floor or in the clinic. Assuming folks aren't going full cowboy and starting central lines or diagnosing and managing severe heart disease on their unit, the stuff we manage is going to be very similar to the stuff NPs and PAs are qualified to manage. The difference is that a few years out of residency and they'll be doing it a lot more and they will be attending the same CME as us to stay current. What will be 10% of our job will be 100% of theirs.

I'm not an internist and don't behave like one, but I'm also not scared to do something if (for instance) a patient doesn't have a PCP for INTERIM care, or to add a 2nd hypertensive if I can't convince my pt to GO to their PCP (which happened all the time at the CMHC I trained at), or order appropriate tests so the speialist I referred to actually has something to look at. At the safety net hospital I worked at, due to the way state grants worked, it wasn't unheard of to qualify for free psych visits, free labs, free meds (I mean "free"), but NOT qualify for PCP visits. So I was just supposed to ignore the COPD, appropriate need for pneumovax, TSH in the 5s, or mild DM2? That's a good way to get my butt sued for negligence. If I were a defense lawyer I'd be all over it.

Oh, no. You are MUCH less likely to be sued for doing your job than you are to be sued for doing someone's for which you lack qualifications.

If you taking on management of COPD and your patient croaks, ANY lawyer's eyes will light up when they find out the treating physician was a psychiatrist. At this point, you can explain that you weren't "scared" and that you had to act as PCP because you couldn't "convince my patient to go to their PCP." You can also explain how you did half an intern year of internal medicine in lieu of the three years that is considered the standard. Well, maybe four months of IM, if you take out neurology. And yes, this all occured before you even had your medical license. This is how you will get your butt sued.

I primarily work in PES or inpatient units and do a lot more physical medicine than most psychiatrists as part of my Army Service. I have plenty of opportunity to read EKGs, run labs, and evaluate charts. I also continue and even tweak medication regimens (though I minimize this as most outpatient docs appreciate that about as much as we do when a PCP changes our psych med regimen). I am fine managing algorithmic med decisions (DM, etc.), though I chart like hell.

But when you start stepping into the actual role of PCP, managing physical medical care longitudinally for a patient, you are operating outside your scope of practice and opening yourself up to legal hurt. Comparing hours and rotations between psychiatrists and NPs/PAs isn't all that helpful, because the difference is that managing these things is their job and not ours.