Lectures for Internal Medicine Residents

[heyjack70]

Hi,
I may have the opportunity to do some lectures for the internal medicine residents at the local community program. What do you think would be some useful topics to cover? I think delirium management would be high yield. And maybe a lecture about common psych drug side effects, what to tell patients, and what to document in the chart. What would an internist want to know about?

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[Manicsleep]

Delirium, dementia, capacity, "mental status change" etc are all things we see often on the consult trail and it is important that they learn about them.

However, the ability to ask questions well and the basic mood, anxiety and psychotic disorders are extremely important. Also, the more you can teach them about management of basic conditions, the better off the health care system will end up. Knowing when to refer is an important skill as well. Given them an idea of how vast psychiatric conditions are and how often they will come across them, regardless of them being in primary care or as a specialist.

 

[sunlioness]

Agree with the above. Risk assessment in suicidal patients is also a good one.

 

[DD214_DOC]

That a consult on a patient with a HISTORY of a psychiatric condition, "just in case" is not appropriate

 

[whopper]

When and when not to order a psychiatric consult.

If ordering a psychiatric consult for deliriuim or dementia, to please have staff do MMSEs every few hours right after the order.

When and when not to order antidepressants. An overview of the antidepressants. (PCPs are the largest group of antidepressant prescribers, not psychiatrists).

Discrimination of psychiatric patients by nonpsychiatrists.

 

[kugel]

View attachment Managing Schizophrenia in the Gen Hosp.pdf

View attachment assessing decisional capcity.pdf

View attachment Sertonin Syndrome NEJM 2005.pdf

View attachment Mgt of Drug&Alcohol W:d 2003.pdf

 

[393656]

I will second that delirium, assessing capacity and suicide evaluation and documention-modifiable v. non-modifiable risk factors etc.

I gave lectures to IM this past year and had success with those topics. I also did one more which was bipolar disorder with a focus on describing symptoms or rather how to pick up more subtle symptoms of bipolar, and other red flags in a history to steer you to bipolar. I did consult work in the outpatient IM clinic and by far the most common things that were going untreated by IM was missed bipolar disorder and missed neurocognitive disorders.

Missed bipolar however can be really costly and with the advent and approval of aypticals for almost everything, a PCP can appropriately treat bipolar if they must (if they cannot get a psych appt for their non-insured patients as it often is).

I do not think many psychiatrists, let alone IM docs really know how to differentiate "racing thoughts" in context of anxiety, worrying or true mania. Decrease in sleep--decrease in NEED for sleep etc etc That is the stuff I emphasized is how to ask proper questions and how to interpret answers.

good luck!

 

[nitemagi]

+1 on the capacity evaluation, including in mgmt of delirious patients. All too often I have had consults where they ask for psychiatric holds for a delirious patient so they can put them in restraints. People do it (though they shouldn't) to help out the medicine (or surgery) team, then the next day get the call "well since they're on a hold can you transfer them to your service?"

The bipolar issue is all too common - and I come from the home of Akiskal
A follow-up question to the "Have you gone several nights without sleeping" should be "well what are you doing all night?" 9/10 times I get the "tossing and turning" answer, which is so not bipolar.

 

[whopper]

I remember every freaking consult for dementia...

And no one bothered to measure the person's mental status over time. If that's the case, how the heck could I tell if that the patient had dementia? I ask the nurse if the person's mental status changed over time and they didn't know. They're answer "That's what you're here for!"

Hmm, I can't spend 5 hours watching a person to do a consult, so I write a note mentioning that the patient needs to be observed over the course of hours and the mental status needs to be checked every so often...and then no one did it.

I mentioned the problem to the attending, but since the attending didn't care, nothing was really accomplished.

 

[393656]

wow jelous of nite-akiskal is the man in psychiatry IMO. I wish more people would odopt his bipolar 11 symptoms.. jk I think his spectrum approach is spot on and the way to look at bipolar disorder especially.

Only thing I do not jive with akiskal (who am I to even argue with him right!! ) is his view that borderline personality is likely a bipolar spectrum disorder. In that case I really do not agree but nonetheless he is one of the few big names I buy into.

Him and the catatonia guru which I cannot think of now.

Speaking of mental status assessments, introducing the MOCA exam as an outpatient tool for picking up subtle frontal lobe defects in neurocognitive disorders. Many present with depression and so many of them at the right age really have some brewing neurocognitive problem that the MOCA can pick up. Depends on thepopulation your IM residents are seeing but mine saw all uninsured people in the county with access to no other doctors so they were really the first line to detect everything. MOCA is my fav tool. EXIT 25 is great but beyond scope of IM.

 

[nitemagi]

Akiskal is a sweet guy but his reputation is accurate that he thinks about everything as being a bipolar variant. Including borderline. He even thinks that love is pathological. I see his perspective on it all, but I don't necessarily agree.

Some his more interesting work is in the area of temperament, such as hyperthymic.

 

[393656]

I like the extremest points of view as long as you are someone who is able to take it with a grain of salt. They often have radical learning points that have truth to them if you defend against the generalizations they make. I think he is absolutely right on with the spectrum of bipolar. Do not think I wuld call it bipolar 3 and 4 but nonetheless I personally think it should be a a three tier system. You are either on or not-on the bipolar spectrum so wuld be diagnosed as bipolar. Then 1, 2 or 3. (Many symptoms, moderate, subtle) would be how I would word it. Treatment is teh same for each etc.

I think that would have utility for justfiying treating bipolar without currently having to say they are having all the classic manic symptoms.

I also think risk factors shouyld be incoprorated like family history, atypical depressive features/seasonal aspect, response to AD etc.

But I agree as long as you can filter these guys, they offer some interesting points of view.