Likelihood of psychiatric +1 in the future

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vancoremed

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I've heard some talk about adding psychiatry +1 options for family medicine doctors. Do you think this is a real possibility and what would it look like?

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I've heard some talk about adding psychiatry +1 options for family medicine doctors. Do you think this is a real possibility and what would it look like?
I have never heard of a true +1 in terms of certification. I don't think it'll ever happen. There are primary care behavioral health fellowships, which can provide additional psychiatric training for primary care docs, and there are 5-year FMP residency programs, but the idea of someone doing 3 yrs of FM followed by a +1 psychiatry program doesn't seem realistic, nor does it seem like anyone with power would be onboard for it.
 
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I have never heard of a true +1 in terms of certification. I don't think it'll ever happen. There are primary care behavioral health fellowships, which can provide additional psychiatric training for primary care docs, and there are 5-year FMP residency programs, but the idea of someone doing 3 yrs of FM followed by a +1 psychiatry program doesn't seem realistic, nor does it seem like anyone with power would be onboard for it.
If it happens, it would likely be similar to EM fellowship where you can't be board certified, will have limited job options and cannot bill the same as someone in the specialty. However, it would still be a good fellowship for anyone that wants to practice in an area that's underserved
 
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If it happens, it would likely be similar to EM fellowship where you can't be board certified, will have limited job options and cannot bill the same as someone in the specialty. However, it would still be a good fellowship for anyone that wants to practice in an area that's underserved
Then it already exists as primary care behavioral health fellowships.
 
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If it happens, it would likely be similar to EM fellowship where you can't be board certified, will have limited job options and cannot bill the same as someone in the specialty. However, it would still be a good fellowship for anyone that wants to practice in an area that's underserved
Yeah, most likely you would just be the one with all the psych patients in a given FM practice. It is unlikely that you could really get a lot of the nuances of treating severe mental illness in one year, but you could probably master the nuances of antidepressantsand anxiety treatments pretty well, as well as learn a pretty comprehensive approach to insomnia. There's a few lrimary care behavioral health fellowships that kind of go this route but honestly I don't know how someone could justify a year of extra training for no financial benefit or board cert.
 
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I have never heard of a true +1 in terms of certification. I don't think it'll ever happen. There are primary care behavioral health fellowships, which can provide additional psychiatric training for primary care docs, and there are 5-year FMP residency programs, but the idea of someone doing 3 yrs of FM followed by a +1 psychiatry program doesn't seem realistic, nor does it seem like anyone with power would be onboard for it.
I think the first 2-yr of FM with the option to do a 2-yr fellowship in psych would be more appropriate. However, it would not work well for FM programs because they would not have some PGY3 residents to use for cheap labor.

It would be good for the marginalized psych patients; they need 1 doctor that can take care all of their issues.
 
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I think the first 2-yr of FM with the option to do a 2-yr fellowship in psych would be more appropriate. However, it would not work well for FM programs because they would not have some PGY3 residents to use for cheap labor.

It would be good for the marginalized psych patients; they need 1 doctor that can take care all of their issues.
Why do you assume that 3rd year is useless to residents, especially as you haven't done an FM residency?

I found it very valuable personally and I'm not alone in that.
 
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Why do you assume that 3rd year is useless to residents, especially as you haven't done an FM residency?

I found it very valuable personally and I'm not alone in that.
I did not say it was useless. If FM were a 4 yrs residency, the 4th yr would not be useless. EM 3 vs 4 years and both of them produce competent docs.
 
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I did not say it was useless. If FM were a 4 yrs residency, the 4th yr would not be useless. EM 3 vs 4 years and both of them produce competent docs.
You basically did though. Otherwise why cut off that third year in favor of 2 years of psych and refer to 3rd years as cheap labor.
 
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You basically did though. Otherwise why cut off that third year in favor of 2 years of psych and refer to 3rd years as cheap labor.
Residency overall is cheap labor...

I just think doing it would be a good thing for marginalized psych patients. If it's an horrendous idea, I am ok to be told it is.
 
Why do you assume that 3rd year is useless to residents, especially as you haven't done an FM residency?

I found it very valuable personally and I'm not alone in that.
Doesn't Canada have 2-year FM residencies? I think many residencies are as long as they are because then they build a lot of redundancy. For example, one FM residency I know has double the OB/Gyn requirement by ACGME, so that's 3 months plus 3 extra months that nobody can really say is crucial because many residents only get the base 3 months. If you look at the minimum requirements of FM, you can do that in 2 years. You could have an entire 3rd year made up from electives, but most programs have their own preferences as to what is important which is why they push on you 3 years. Saying that you could do 2 years plus 2 psych years is not unreasonable given you met the minimum FM training
 
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Doesn't Canada have 2-year FM residencies? I think many residencies are as long as they are because then they build a lot of redundancy. For example, one FM residency I know has double the OB/Gyn requirement by ACGME, so that's 3 months plus 3 extra months that nobody can really say is crucial because many residents only get the base 3 months. If you look at the minimum requirements of FM, you can do that in 2 years. You could have an entire 3rd year made up from electives, but most programs have their own preferences as to what is important which is why they push on you 3 years. Saying that you could do 2 years plus 2 psych years is not unreasonable given you met the minimum FM training
I would suggest there's a difference between doing the bare minimum and actually producing high quality family physicians.
 
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I would suggest there's a difference between doing the bare minimum and actually producing high quality family physicians.

Are Canadian family physicians not high quality? Is there training program different? Like do they do a rotating internship and then 2 years of FM, or do they just do 2 years of FM out of med school?
 
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Are Canadian family physicians not high quality? Is there training program different? Like do they do a rotating internship and then 2 years of FM, or do they just do 2 years of FM out of med school?
No idea, I didn't grow up, live, or train in Canada so their system doesn't matter to me. Plenty of places that will license a GP with an intern year only. Our system works well for us, I would need exceptionally compelling evidence to change our system.

If you're actually seriously interested, I suspect med school is more rigorous in other places. There's almost daily complaints from students here on SDN complaining about how little they do 3rd/4th years. I would wager that's not an issue in other countries like it is here (though that's pure speculation on my part).
 
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No idea, I didn't grow up, live, or train in Canada so their system doesn't matter to me. Plenty of places that will license a GP with an intern year only. Our system works well for us, I would need exceptionally compelling evidence to change our system.

If you're actually seriously interested, I suspect med school is more rigorous in other places. There's almost daily complaints from students here on SDN complaining about how little they do 3rd/4th years. I would wager that's not an issue in other countries like it is here (though that's pure speculation on my part).

Yeah, it was an actual question. Cause if med school is comparable, FM residency is only two years, and they’re putting out the same quality of FM docs, then it’s hard to argue that 3 years is really necessary.
 
Are Canadian family physicians not high quality? Is there training program different? Like do they do a rotating internship and then 2 years of FM, or do they just do 2 years of FM out of med school?
I know a Canadian where attended med school that did the 2 yr FM in Canada. He is practicing in NY now.
 
I know a Canadian where attended med school that did the 2 yr FM in Canada. He is practicing in NY now.

Yeah I dunno what Canadian med schools are like or what the quality of the docs are after they graduate those two years. Could be great. I just have no idea.
 
Yeah I dunno what Canadian med schools are like or what the quality of the docs are after they graduate those two years. Could be great. I just have no idea.
Med school curriculum in Canada is eidentical to ours here. The only difference is that it's more competitive to get into med school in Canada.
 
Med school curriculum in Canada is eidentical to ours here. The only difference is that it's more competitive to get into med school in Canada.
The question then becomes are the curricula the same in practice, not just on paper.
 
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My opinion as a psychiatrist. The behavioral health 1 year fellowships are great if you want to boost your skills anticipating a lot of outpatient psych in your family med practice.

But it won't prepare you to be a psychiatrist. You won't be able to bill for psychotherapy because you won't have the training. The fellowship may have some exposure to inpatient psych, but likely no consults or ED or enough addiction exposure, which are very unique arenas for psychiatric work. So it's unlikely you can do inpatient psych work. Given the amount to learn in psych residency the 3 year residency on top is very reasonable.

But you can see as many patients with mental illness in outpatient as you would want. Which you could always do before, you'll just be better prepared for it.
 
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You basically did though. Otherwise why cut off that third year in favor of 2 years of psych and refer to 3rd years as cheap labor.
Based on his proposal, why do I need four years of psych then 😂 Let's just make psych two years and be done with it! What could go wrong!

The nuances of psychiatry are *very* difficult to get a handle on and require a great number of patients to nail down. This is partly the nature of psychiatric treatment itself, as no two brains are alike and you never know who will respond to what. Plus half of psych is using side effects to your advantage and working at the edge of FDA approval. It's just not something that can be done competently in one year, though two years could get some degree of competemce with some subsets of patients. Inpatient or severe mental illness though? No way.
 
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Based on his proposal, why do I need four years of psych then 😂 Let's just make psych two years and be done with it! What could go wrong!

The nuances of psychiatry are *very* difficult to get a handle on and require a great number of patients to nail down. This is partly the nature of psychiatric treatment itself, as no two brains are alike and you never know who will respond to what. Plus half of psych is using side effects to your advantage and working at the edge of FDA approval. It's just not something that can be done competently in one year, though two years could get some degree of competemce with some subsets of patients. Inpatient or severe mental illness though? No way.
I wonder why there are 5-yr med/psych or FM/psych program... Shouldn't they be 6.5-7yrs if we are looking at absolute #?
 
I wonder why there are 5-yr med/psych or FM/psych program... Shouldn't they be 6.5-7yrs if we are looking at absolute #?
Core psychiatry requirements are one year of continuous outpatient psychiatric treatment with a patient panel that you follow, approximately 4 hours per week of psychotherapy and supervision (this is more flexible, you have to be competent in three forms of psychotherapy, whatever that means), six months of inpatient psychiatry, two months of child and adolescent, one month of geriatrics, one month of addiction, two months of consultation/liaison, ER "experience" in suicide risk assessment and treatment, forensic "experience" (both of these are generally expected to amount to at least one FTE), and two months of neurology. So you could compress psychiatry training down to 28 months, but as with most specialties, it is expected that you do at least a few electives in a specialty. I'd say the old 36 month+internship model is just fine for psych, but the 48 month straight probably results in psychiatry residents that come out of the gate with stronger skills in psychiatry and marginally weaker skills in medicine.

FM you need six months of medical inpatient care, one month of ICU, two months of emergency medicine, two months of acute pediatric care, two months of ambulatory pediatrics, two months of MSK/sports med, one month of OB, two months of gynecology, one month of health management systems, and three months of electives. They also need to have a 24 month continuous clinic experience with at least 1750 patient encounters in the adult ambulatory setting, so assuming you do all of these things and somehow compress them into 24 months (good luck!), and you combine this with the 28 from psych, that gives you 52 months. Realistically you'll need more time than this for your FM clinic given other service requirements, and you'll need some electives to round out your training on both sides of things. So that's how you get 5 years for both specialties, I guess. Minimum you could argue to be competently trained in a compressed psychiatry curriculum would be just shy of 2.5 years, and at that point why not just find a program that lets you use your intern year to come on board and sign up for a full psych residency starting as a PGY-2.
 
I would suggest there's a difference between doing the bare minimum and actually producing high quality family physicians.
So combined FM/Psych where they do the minimum of both you're ready to say they aren't high quality FM or Psych?
 
I wonder why there are 5-yr med/psych or FM/psych program... Shouldn't they be 6.5-7yrs if we are looking at absolute #?
Core psychiatry requirements are one year of continuous outpatient psychiatric treatment with a patient panel that you follow, approximately 4 hours per week of psychotherapy and supervision (this is more flexible, you have to be competent in three forms of psychotherapy, whatever that means), six months of inpatient psychiatry, two months of child and adolescent, one month of geriatrics, one month of addiction, two months of consultation/liaison, ER "experience" in suicide risk assessment and treatment, forensic "experience" (both of these are generally expected to amount to at least one FTE), and two months of neurology. So you could compress psychiatry training down to 28 months, but as with most specialties, it is expected that you do at least a few electives in a specialty. I'd say the old 36 month+internship model is just fine for psych, but the 48 month straight probably results in psychiatry residents that come out of the gate with stronger skills in psychiatry and marginally weaker skills in medicine.

FM you need six months of medical inpatient care, one month of ICU, two months of emergency medicine, two months of acute pediatric care, two months of ambulatory pediatrics, two months of MSK/sports med, one month of OB, two months of gynecology, one month of health management systems, and three months of electives. They also need to have a 24 month continuous clinic experience with at least 1750 patient encounters in the adult ambulatory setting, so assuming you do all of these things and somehow compress them into 24 months (good luck!), and you combine this with the 28 from psych, that gives you 52 months. Realistically you'll need more time than this for your FM clinic given other service requirements, and you'll need some electives to round out your training on both sides of things. So that's how you get 5 years for both specialties, I guess. Minimum you could argue to be competently trained in a compressed psychiatry curriculum would be just shy of 2.5 years, and at that point why not just find a program that lets you use your intern year to come on board and sign up for a full psych residency starting as a PGY-2.

To clarify combined training a little: there are overlapping requirements including psychiatry for FM and inpatient/ambulatory medicine for psych. There are also a number of electives in both that amount to roughly 6 mos in FM and 8-12 mos in Psych.

Sequential training is typically done in 6 years, as the second specialty will likely give credit for roughly a year's worth of GME from the first specialty. In addition, the reduced elective time (ultimately you are doing your electives in the other specialty) results in a curriculum for combined training that fulfills both requirements in 5 years.

Every combined program still has a few electives but they are substantially reduced because of the amount of "elective" time spent fulfilling the requirements of the other specialty.

Also, one correction, the required continuity encounters for FM is 1650 along with specific geriatrics and peds requirements as well as number of weeks in continuity clinic per year. Psych on the other hand doesn't have quantitative encounter requirements, but rather requires a certain amount of time and "exposure" as well as a required continuous 12 months of outpatient as described above by @Mad Jack .
 
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If I spend 4-5 yrs in internal medicine, of course I will be stronger coming out of residency. The question is at what point do you consider someone competent?

A 2-yr well structured psych fellowship for FM docs should be good enough to make most FM docs competent to practice psychiatry. There is a need for it.
 
So combined FM/Psych where they do the minimum of both you're ready to say they aren't high quality FM or Psych?
Possibly. If you take 2 identical students and put one in a pure FM program and one in FM/Psych (assuming equal strength of programs) then yes, the pure FM one is likely to be better.

But the combined program residents usually start out stronger (you see this with med/peds as well) so the outcomes in my experience tend to be similar.
 
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Based on his proposal, why do I need four years of psych then 😂 Let's just make psych two years and be done with it! What could go wrong!

The nuances of psychiatry are *very* difficult to get a handle on and require a great number of patients to nail down. This is partly the nature of psychiatric treatment itself, as no two brains are alike and you never know who will respond to what. Plus half of psych is using side effects to your advantage and working at the edge of FDA approval. It's just not something that can be done competently in one year, though two years could get some degree of competemce with some subsets of patients. Inpatient or severe mental illness though? No way.

I honestly think we're pulling at hairs here. There is tremendous overlap between non-surgical specialties. I think there gets to be a point where we make things asinine for the sake of saying that the competencies decided upon are scripture. Hell, we bent those competencies for the last 2 years and I doubt anyone is going to be worse for it.

Like can you honestly say that someone who graduated from an EM program decided they wanted to get more Psych training needs to do 3.5 whole years to get board certified despite them having years of treating drug and alcohol withdrawal, acutely psychotic people, delirium, etc?
 
I honestly think we're pulling at hairs here. There is tremendous overlap between non-surgical specialties. I think there gets to be a point where we make things asinine for the sake of saying that the competencies decided upon are scripture. Hell, we bent those competencies for the last 2 years and I doubt anyone is going to be worse for it.

Like can you honestly say that someone who graduated from an EM program decided they wanted to get more Psych training needs to do 3.5 whole years to get board certified despite them having years of treating drug and alcohol withdrawal, acutely psychotic people, delirium, etc?
I think three years is about the right amount. The problem with psych is that you need a long period of time to see the appropriate depth and breadth of severe mental illness that allows one to really be a psychiatrist. Sorting out just one difficult case can be a six month plus affair, and learning to really split the hairs on what diagnosis is what is the thing that separates a psychiatrist from any other physician practicing mental health. The other big difference is adequate training in therapy, which other physicians just don't get. I almost exclusively treat patients that PCPs have thrown up their hands in frustration at treating, ones that have complex cocktails of severe mental illness, extensive trauma histories, psychosis of many different flavors, insomnia, substance use, and suicide attempts. I don't get called on the inpatient service to manage basic agitation, I get called when all the basics have failed. Patients don't wait six months to get on our panel to treat uncomplicated depression that could have been managed by their PCP.

Part of the problem with psychiatry is that every case is unique. There is no such thing as a garden variety case of depression, nor a cookie cutter approach to assessment and treatment of same. This same principle applies to bipolar disorder, schizophrenia, ADHD, OCD, delusional disorder, eating disorders, substance use disorders, dementia, delirium, and all manner of psychiatric illness and cognitive disturbance. Because of the sheer vast nature of presentations, coupled with the fact that the only tool you have to assess these patients 98% of the time is a very carefully calibrated mind and interview, and throw in a formulary that has little overlap with the day-to-day practice of most specialties and you've got a pretty easy to justify three years minimum of training.
 
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