Is Psychiatry really “just medication management”?

[michaelrack]

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searching for medical causes of psychosis. It isn't up to medicine to find out whether my patient has psychosis secondary to lupus, syphilis, or thyroid issues, for instance.

I don't consider ordering a TSH or RPR complex diagnostic testing. Now if a psychiatrist performs and interprets an LP to look for a secondary cause of lupus, then that would count. I would even count it if a psych resident orders a specialized antibody panel to to look for a CNS auto-immune vasculitis. In real post-resident life, psychiatrists don't do this.
Please note that when I refer to complex diagnostic testing by endocrinology, I am referring to things like checking hormones multiple times in a day under various situations (salt loading, water deprivation, glucose load, etc) to make a precise diagnose/localize.

 

[michaelrack]

Genetic testing requires interpretation to use properly. If you're just going by color codes and not reading and understanding the individual genes involved you're doing your patients a disservice.

I haven't been impressed by the Genesight reports, but I guess they have a place as part of good med managment

 

[WisNeuro]

Pharmacogenetic testing is the diagnostic approach of the future and I fear it always will be. Regardless at present the evidence is very, very shaky for actual clinical utility. As a hail Mary whatevs but I don't think it conveys all that much information-theoretic terms wrt med choice nor should it meaningfully impact your priors.

Not to mention that psychiatric/genetic studies have some of the lower reproducibility rates in the psychiatry/psychology literature.

 

[Mad Jack]

that's part of med management

That requires the ordering and interpretation of tests that can affect the course of treatment

 

[Mad Jack]

I don't consider ordering a TSH or RPR complex diagnostic testing. Now if a psychiatrist performs and interprets an LP to look for a secondary cause of lupus, then that would count. I would even count it if a psych resident orders a specialized antibody panel to to look for a CNS auto-immune vasculitis. In real post-resident life, psychiatrists don't do this.
Please note that when I refer to complex diagnostic testing by endocrinology, I am referring to things like checking hormones multiple times in a day under various situations (salt loading, water deprivation, glucose load, etc) to make a precise diagnose/localize.

I mean, it's as complicated as many specialties will get, in the sense that the complicated part lies in knowing what to look for and order in the first place. Regardless, I feel like goalposts keep getting moved and my original point was that psychiatrists order and interpret tests. You may not find those tests interesting, but I'm perfectly content with it

 

[Stagg737]

Do people really do 5 med mgmt visits an hour??? That just sounds crazy to me.

And yes, you can beat this with cash only with only therapy.

Yes, had an attending who would do 6 per hour (3 med refills on the top of the hour every hour then 1 appt at xx:15, xx:30, and xx:45). The first three each hour were always patients he'd had for 5+ years who were there for just a refill with no med changes or new complaints. Other 3 could be minor med changes or a new symptom. Did 1-2 new patient appts/wk (wait list was 8ish months for a new patient to see him). Did not run a pill-mill and the majority of patients were extremely stable and he'd had them for years.

One could argue that such simple and straight forward patients should be managed by their PCP or mid-levels, but he said after doing that for several years and seeing his med recs changed and then watching patients decompensate, he does not trust non-psychiatrists (or even some psychiatrists) to manage his patients.

 

[dl2dp2]

Yes, had an attending who would do 6 per hour (3 med refills on the top of the hour every hour then 1 appt at xx:15, xx:30, and xx:45). The first three each hour were always patients he'd had for 5+ years who were there for just a refill with no med changes or new complaints. Other 3 could be minor med changes or a new symptom. Did 1-2 new patient appts/wk (wait list was 8ish months for a new patient to see him). Did not run a pill-mill and the majority of patients were extremely stable and he'd had them for years.

One could argue that such simple and straight forward patients should be managed by their PCP or mid-levels, but he said after doing that for several years and seeing his med recs changed and then watching patients decompensate, he does not trust non-psychiatrists (or even some psychiatrists) to manage his patients.

Hm. I guess this is one way to do things. I'm happy where I am with represents a completely different model. Kudos to him but I doubt (and am certainly) not trained for this way of doing things.

Also, to be fair, most of my patients are quite a bit sicker--though I go out of my way to address issues that are untouched by meds.

 

[Stagg737]

Hm. I guess this is one way to do things. I'm happy where I am with represents a completely different model. Kudos to him but I doubt (and am certainly) not trained for this way of doing things.

Also, to be fair, most of my patients are quite a bit sicker--though I go out of my way to address issues that are untouched by meds.

Yea, it's definitely a tough way to work and this attending is a total beast/work-horse. I really enjoyed the rotation for the few weeks I was there, but I couldn't maintain that schedule in the long-term.

I think it also requires a certain patient population which I think takes time, skill, and reputation to actually build as many of his long term patients ended up with him after he treated them as inpatients. He also makes it clear to patients that he does not do psychotherapy (he has 4-5 psychologists who work under him for that) and that his outpt appointments are for their pharmacologic treatment only (though I have seen him do some therapy when it's warranted). So it's a specific treatment for a specific population without much variation. Might seem unethical to some, but given the shortage of mental health professionals in the area docs can pretty much do whatever they want in terms of who and how they treat and can fill their clinics (for now).

 

[michaelrack]

I mean, it's as complicated as many specialties will get, in the sense that the complicated part lies in knowing what to look for and order in the first place. Regardless, I feel like goalposts keep getting moved and my original point was that psychiatrists order and interpret tests. You may not find those tests interesting, but I'm perfectly content with it

fine, you and other psychiatrists order and interpret tests. I agree with that. I just didn't like the comparison to an endocrinologist that was made.

 

[Mad Jack]

fine, you and other psychiatrists order and interpret tests. I agree with that. I just didn't like the comparison to an endocrinologist that was made.

The point wasn't a comparison, the point was that saying basically any medical field that doesn't involve procedures is med management is stupid, because they're all complex, nuanced, and challenging.

 

[clausewitz2]

Hm. I guess this is one way to do things. I'm happy where I am with represents a completely different model. Kudos to him but I doubt (and am certainly) not trained for this way of doing things.

Also, to be fair, most of my patients are quite a bit sicker--though I go out of my way to address issues that are untouched by meds.

Hearing about this model I am just struck by - sure, okay, your patients who have been stable for years probably most of the time don't need much more than 5 minutes really. But a) how do you guarantee they'll never need more time - run even a little bit over in an early appointment and you spend the rest of the day seeing dozens of people pissed because you are late and b) if they are so stable you can guarantee they will not need more than 5 minutes, why do they need a psychiatrist v. a letter to their PCP outlining the drugs you prescribed and sending them on their way?

I have met two people who practice in this way and what they had in common was that they both trained in India. Where they trained, they were expected to work at this sort of tempo because they were the only clinic for several million people and so would have a hundred patients show up in a given day. Any chance the attending you are talking about trained in the subcontinent, @Stagg737 ?

I understand points about access but there is some point as you decrease appointment times that the utility of the visit is indistinguishable from zero (apart from issues of possible harm from a false sense of security). I don't know where that lies in all cases, but five minute appointments have got to be skating right on the edge.

 

[clausewitz2]

I don't consider ordering a TSH or RPR complex diagnostic testing. Now if a psychiatrist performs and interprets an LP to look for a secondary cause of lupus, then that would count. I would even count it if a psych resident orders a specialized antibody panel to to look for a CNS auto-immune vasculitis. In real post-resident life, psychiatrists don't do this.
Please note that when I refer to complex diagnostic testing by endocrinology, I am referring to things like checking hormones multiple times in a day under various situations (salt loading, water deprivation, glucose load, etc) to make a precise diagnose/localize.

We could always bring back the DST.... (mostly kidding)

If psychoneuroimmunology ever takes off we could be ordering significantly more sophisticated lab tests but I am not holding my breath.