Malignant Programs

[notdeadyet]

We are the last point of quality control.

It seems to me that quality control in the production of doctors gets shunted to the next system (this would make a great paper; maybe someone has already written it?). Pardon me if this comes across as overly provocative (I have been riding a caffeine wave for three days preparing for a case):

QA certainly doesn't happen at the entry to medical school level. If you include allopathic, osteopathic, and international medical schools, pretty much anyone capable of graduating college successfully can get into medical school if they are willing to go anywhere and pay anything.

QA doesn't typically happen at the medical school graduation level. I'm not sure of the stats in general, but last I heard, U.S. allopaths graduate at a rate of about 95%. When you rule out folks who change careers, have health consequences, etc., I've heard that it's only about 1.5% of U.S. allopaths not graduating due to academic reasons. I know firsthand from doing education rep work in medical school that programs bend over backwards to make sure each person gets through the year. In ways that far exceed even what your average community college would do to get folks passed.

QA doesn't seem to happen at the residency level either. I'd be curious to hear from PDs on this, but I know that residents being kicked out for poor performance is extremely low, even in psychiatry (which although rising in competition is still not up there in requirements). I have met many, many residents that I would not want to refer patients to. And almost all folks I have heard about (in substantiated ways) that were kicked out from residency were for professionalism (sex, drugs, etc.) reasons rather than can't-execute-even-the-fundamentals. SDN seems rife with applicants wanting to tar any program that has ever given a resident the boot, even prior to hearing about circumstances.

QA doesn't seem to happen post-residency level much at all. From doing malpractice cases, I feel comfortable saying that a psychiatrists abilities have to be at the point of outright dangerous before they will lose their license or even get reprimanded.

I have no solutions. I just find it interesting that for such a safety-oriented field, we do not have a very good quality assurance process for how we create doctors.

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[Merovinge]

I reckon half the gripes people on SDN have about the field of psychiatry are problems mostly attributable to people who have no business being doctors/psychiatrists being passed along and allowed to practice as doctors/psychiatrists.

I tire of the "participation trophy" mentality. Just because you feel you deserve to be a doctor doesn't mean you have some right to. If you can't demonstrate competency, you shouldn't be out there practicing.

Don't mean to sound harsh, and god knows enforcing this justly is challenging and problematic, but to not even bother try and give anyone who scramble their way into any medical school a gold sticker to practice medicine because the alternate is just so bad doesn't cut it.

I agree with the sentiment, but let's be honest, programs aren't failing people for clinical acumen or ability to deliver competent care. I wish there was some system that stopped clinicians who had track records of reckless prescribing repeatedly or 3+ SD over the mean of surgical complications but this is not what people are getting fired for. Disagreeing with a chair/PDs work style/belief system are almost always what I hear people getting into trouble or let go for (along with sheer laziness and just not showing up). People getting let go in the 2nd half of residency were somehow able to care for 100's/1000's of patients before that time, so clearly it's something other than ability to competently practice medicine.

 

[downwithDTB]

It seems to me that quality control in the production of doctors gets shunted to the next system (this would make a great paper; maybe someone has already written it?). Pardon me if this comes across as overly provocative (I have been riding a caffeine wave for three days preparing for a case):

QA certainly doesn't happen at the entry to medical school level. If you include allopathic, osteopathic, and international medical schools, pretty much anyone capable of graduating college successfully can get into medical school if they are willing to go anywhere and pay anything.

QA doesn't typically happen at the medical school graduation level. I'm not sure of the stats in general, but last I heard, U.S. allopaths graduate at a rate of about 95%. When you rule out folks who change careers, have health consequences, etc., I've heard that it's only about 1.5% of U.S. allopaths not graduating due to academic reasons. I know firsthand from doing education rep work in medical school that programs bend over backwards to make sure each person gets through the year. In ways that far exceed even what your average community college would do to get folks passed.

QA doesn't seem to happen at the residency level either. I'd be curious to hear from PDs on this, but I know that residents being kicked out for poor performance is extremely low, even in psychiatry (which although rising in competition is still not up there in requirements). I have met many, many residents that I would not want to refer patients to. And almost all folks I have heard about (in substantiated ways) that were kicked out from residency were for professionalism (sex, drugs, etc.) reasons rather than can't-execute-even-the-fundamentals. SDN seems rife with applicants wanting to tar any program that has ever given a resident the boot, even prior to hearing about circumstances.

QA doesn't seem to happen post-residency level much at all. From doing malpractice cases, I feel comfortable saying that a psychiatrists abilities have to be at the point of outright dangerous before they will lose their license or even get reprimanded.

I have no solutions. I just find it interesting that for such a safety-oriented field, we do not have a very good quality assurance process for how we create doctors.

Not sure this is a totally fair assessment, and I don't think that the stats actually exist... but there is selection (not great) at the level of med school admissions and then at the level of foreign grad admission to residencies. The stats don't really exist, but while pretty much everyone who gets into a US MD school gets to finish residency as long as they can pass the steps and mostly show up... I don't believe that this is the case for people who go to non-US schools. So while anyone with money can enrol in a med school somewhere, there is a limit on the number of those who get into residency.

This double checkpoint (pass either the admission to US MD or do well at the residency landing stage) is the only major QI control, and while I'm not arguing that it's effective or done well, it does exist.

 

[clausewitz2]

Not sure this is a totally fair assessment, and I don't think that the stats actually exist... but there is selection (not great) at the level of med school admissions and then at the level of foreign grad admission to residencies. The stats don't really exist, but while pretty much everyone who gets into a US MD school gets to finish residency as long as they can pass the steps and mostly show up... I don't believe that this is the case for people who go to non-US schools. So while anyone with money can enrol in a med school somewhere, there is a limit on the number of those who get into residency.

This double checkpoint (pass either the admission to US MD or do well at the residency landing stage) is the only major QI control, and while I'm not arguing that it's effective or done well, it does exist.

This. Also, add the attrition rate at the Caribbean schools (at least, the big ones anyone has ever heard of), where being allowed to graduate is definitely not to be taken for granted.

 

[GUH]

It seems to me that quality control in the production of doctors gets shunted to the next system (this would make a great paper; maybe someone has already written it?). Pardon me if this comes across as overly provocative (I have been riding a caffeine wave for three days preparing for a case):

QA certainly doesn't happen at the entry to medical school level. If you include allopathic, osteopathic, and international medical schools, pretty much anyone capable of graduating college successfully can get into medical school if they are willing to go anywhere and pay anything.

QA doesn't typically happen at the medical school graduation level. I'm not sure of the stats in general, but last I heard, U.S. allopaths graduate at a rate of about 95%. When you rule out folks who change careers, have health consequences, etc., I've heard that it's only about 1.5% of U.S. allopaths not graduating due to academic reasons. I know firsthand from doing education rep work in medical school that programs bend over backwards to make sure each person gets through the year. In ways that far exceed even what your average community college would do to get folks passed.

QA doesn't seem to happen at the residency level either. I'd be curious to hear from PDs on this, but I know that residents being kicked out for poor performance is extremely low, even in psychiatry (which although rising in competition is still not up there in requirements). I have met many, many residents that I would not want to refer patients to. And almost all folks I have heard about (in substantiated ways) that were kicked out from residency were for professionalism (sex, drugs, etc.) reasons rather than can't-execute-even-the-fundamentals. SDN seems rife with applicants wanting to tar any program that has ever given a resident the boot, even prior to hearing about circumstances.

QA doesn't seem to happen post-residency level much at all. From doing malpractice cases, I feel comfortable saying that a psychiatrists abilities have to be at the point of outright dangerous before they will lose their license or even get reprimanded.

I have no solutions. I just find it interesting that for such a safety-oriented field, we do not have a very good quality assurance process for how we create doctors.

Should non-dangerous doctors lose their licenses?

 

[whopper]

Agree with so many of the comments above. I see so many terrible doctors. It doesn't matter the field. It's in all fields, but the problem is less transparent in psychiatry due to the diagnosis based on symptoms and signs without lab validation.
I do know for a fact that while I was a resident another resident a year ahead of me was let by that everyone knew wasn't good cause his aunt was an attending in the program. That was kept secret but when I became chief this was made known to me. IMHO he shouldn't have been allowed to graduate.

Kicking out residents can be difficult. Not because it's impossible. It's not, it's because it's inviting a lawsuit. I've seen cases where a resident was in trouble, they get put on probation, and the resident gets a lawyer, so the program wimps out. I've seen cases where this leads to tremendous problems.

E.g. one program-and this is real the program kicked out the resident, she threatened a lawsuit, they settled out of court. The settlement involved the program agreeing to never release her records because they were quite damning. Well guess what? GME requires that programs that kick out residents give their records to the new program if the resident gets into one and the new program asks for it. That resident got into a new program, they found out she was in a prior program (that resident lied about being in the previous program,) and when the new program asked for the records from the old, the old was put in a very bad position cause the settlement they promised upon was for them to not release the records.

 

[MacDonaldTriad]

This is the dialectic, after 8 years of college and 2-3 years of post graduate training, it is a little late to tell someone they are not cutting it, and sometimes it is true. Training directors don't earn their money when everyone is doing well, they earn it when someone isn't. It is hard to fire someone and it should be, it should also be possible. Training director incompetence is often a lack of knowledge of HR rules and of the progressive discipline documentation required that can allow for dismissal. Fortunately very few of us have to do this very often and that is why we are sometimes bad at it. It is the job of the DIOs to be a resource when things go poorly.

 

[Shikima]

This is the dialectic, after 8 years of college and 2-3 years of post graduate training, it is a little late to tell someone they are not cutting it, and sometimes it is true. Training directors don't earn their money when everyone is doing well, they earn it when someone isn't. It is hard to fire someone and it should be, it should also be possible. Training director incompetence is often a lack of knowledge of HR rules and of the progressive discipline documentation required that can allow for dismissal. Fortunately very few of us have to do this very often and that is why we are sometimes bad at it. It is the job of the DIOs to be a resource when things go poorly.

Very illuminating.

 

[hamstergang]

I agree with the sentiment, but let's be honest, programs aren't failing people for clinical acumen or ability to deliver competent care.

I don't know if I agree with your definition of honest. Based on the threads I see on SDN, I very much believe that programs are failing residents for being poor at delivering competent care. Not all, but it's certainly happening.

 

[nancysinatra]

We are the last point of quality control. If medical schools graduate problems, and we graduate problems, no one has to board certify to practice. Shouldn't there be a certain % who are not fit intellectually or emotionally to practice competently? There isn't a specialty out there that hasn't had to flunk a trainee at some time. It isn't just psychiatry. If there is a specialty where everyone match graduates, someone isn't doing their job. It would be nice if everyone developed smoothly into competent physicians, but that just isn't the reality.

I see what you mean, but what I meant was more along the lines of: why is it HARD for you, as a PD, to NOT graduate such a person? As a PD, the occasional firing is part of your job, right? I realize it must be painful and awkward - but worse than seeing a good resident leave the program? That seems turned around to me. I think sometimes in psychiatry we get overly emotional about our training process, and we fixate on people's personalities, putting their "traits" under a microscope rather than their board scores or their competency. Sometimes the results are pretty skewed. But it seems to me it should always be harder to see a good person leave than let a bad person stay. If someone is not cut out for psychiatry, you are doing them a favor by letting them know - the earlier, the better, too (and obviously, in a compassionate manner).

I'm sure it's hard in any field to fire a resident, but some specialties seem to make it easier. Some programs (surgery comes to mind) have a pyramidal structure where weeding out is the rule. Other programs set mandatory scores on in-service exams. It may seem ruthless and Darwinian, but since when is that new in medicine? Do you think plastic surgery PD's go around worrying about graduating incompetent residents? Probably not that much. So maybe there is something to say for those specialties where all people care about is external accomplishments.

The other thing that comes to mind with these responses is - look at all the NP programs that are popping up. Some of them are not exactly the highest quality. If you fire a psych resident, even the most incompetent one, the job they would have taken after graduation could be taken by an even worse midlevel. (Which is not meant as an insult to all midlevels. I know many fantastic ones. But there is a range.) So how can we be sure that when bad residents are let go, it helps society? Maybe it doesn't!

 

[MacDonaldTriad]

It is hard to fire a resident because of all of the contractual safe guards and required monitoring and remediation. Verbal warnings, written warnings, written plans of correction with clear progress anchor points, formal probation... "Professionalism" is the hardest to remediate because it has the least measurable outcomes and is the most resistant to learning. These have to either reach into the arena of criminal, or be shy of that and lawyers get involved when you take action. Residency is a job and all of the labor laws are in place.

From what I have experienced, plastic surgery has just as many problems as psychiatry. Even if we are not as smart, we respond to knowledge based remediation very well, and plastic surgeons are just as vulnerable to the other short comings as we are. Its always those things not in the dean's letters that may have been noticed in medical school, but not communicated.

 

[whopper]

The standards that make someone become a good physician don't correlate well with what most medical schools use-standardized board exams and class grades. Dedication, empathy for patients, common sense, out-of-the-box thinking, crystalline intelligence, leadership with hospital staff, these are things that are extremely important that are not tested in medical school.

I have no problem whatsoever kicking out a resident that wasn't trying, lying, or showing some type of unethical behavior. I do, however, feel incredible sorrow when I see a resident not performing well but due to something they're sincerely trying to improve upon.

 

[MacDonaldTriad]

The pressure to become a physician is intense and partly to blame. I know I have a very Western, non-collectiveness view on the world, but collectivism will not keep you doing your duty if you hate what you do. If you see the edge of the waterfall, paddle to shore. If you are turned on about being a psychiatrist, full speed ahead. I wrote a lot more, but I would have offended a lot of cultural values, so I deleted it.

 

[Doctor Bagel]

The standards that make someone become a good physician don't correlate well with what most medical schools use-standardized board exams and class grades. Dedication, empathy for patients, common sense, out-of-the-box thinking, crystalline intelligence, leadership with hospital staff, these are things that are extremely important that are not tested in medical school.

I have no problem whatsoever kicking out a resident that wasn't trying, lying, or showing some type of unethical behavior. I do, however, feel incredible sorrow when I see a resident not performing well but due to something they're sincerely trying to improve upon.

Why do we spend so much time dismissing things that we're good at? Stick-to-itiveness, follow through and a base level of intelligence can be measured by things like grades, volunteering, standardized tests, etc.. While there certainly are flaws in the medical school admission system, I think the system generally works. We pay attention to the very small number of residents and physicians who are doing a bad job while missing that most of us are actually doing OK and were trained in an overall functional (if not perfect) system.

 

[MacDonaldTriad]

I agree with you. For the most part people are well trained. A lot of good people are not allowed in and a few bad ones are. That is about as good as it will ever be.

 

[W19]

The other thing that comes to mind with these responses is - look at all the NP programs that are popping up. Some of them are not exactly the highest quality. If you fire a psych resident, even the most incompetent one, the job they would have taken after graduation could be taken by an even worse midlevel. (Which is not meant as an insult to all midlevels. I know many fantastic ones. But there is a range.) So how can we be sure that when bad residents are let go, it helps society? Maybe it doesn't!

The SDN answer: We have to protect the medical brand.

 

[doc4us]

The standards that make someone become a good physician don't correlate well with what most medical schools use-standardized board exams and class grades. Dedication, empathy for patients, common sense, out-of-the-box thinking, crystalline intelligence, leadership with hospital staff, these are things that are extremely important that are not tested in medical school.

I have no problem whatsoever kicking out a resident that wasn't trying, lying, or showing some type of unethical behavior. I do, however, feel incredible sorrow when I see a resident not performing well but due to something they're sincerely trying to improve upon.

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[doc4us]

As you often do you got it right Whopper and got me thinking. When you say we need to "think outside the box" what exactly does that mean for us. Presumably in our clinical work we strive to practice evidence-based medicine. If evidence-based medicine is the "box," when do we practice outside of it. I'm not trying to be flippant. Just curious as to some clinical examples of what it looks like to think "outside of the box" in our practice.


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[splik]

As you often do you got it right Whopper and got me thinking. When you say we need to "think outside the box" what exactly does that mean for us. Presumably in our clinical work we strive to practice evidence-based medicine. If evidence-based medicine is the "box," when do we practice outside of it. I'm not trying to be flippant. Just curious as to some clinical examples of what it looks like to think "outside of the box" in our practice.


Sent from my iPhone using SDN mobile app

I am a big fan of evidence based practice, but there are different kinds of evidence as well as different levels of evidence. some people have a very caricatured idea of what EBM is that would have David Sackett turning in his grave. At the same time the reality is that much of what we practice is in a evidence free zone. This is not just true of psychiatry but all of medicine. There are only large randomized controlled trials for certain things, and RCTs are neither necessary nor sufficient for establishing the evidence base for particular interventions. Even for those interventions that have been studied, the harms often are not (particularly in the case of psychotherapies, RCTs rarely report or study adverse events). Treatment in psychiatry starts with a good formulation and theoretical justification for the management plan. Being able to formulate a patient from multiple perspectives should be the essential skill of the psychiatrist and requires one to think "outside the box".

Another aspect of the "box" in diagnostic psychiatry is a very limited framework for conceptualizing mental distress - the DSM. Psychiatric diagnoses carve nature at the joints, are categorical rather than dimensional, assume mental disorders as "natural kinds" rather than "ideal types", and are shaped by cultural and sociopolitical factors more than medical or psychological ones. Thinking outside the box means being able to think outside the straightjacket of the DSM, a system of diagnosis that was meant to serve as guidebook and common language for the field and instead has been reified as a "bible". Plenty of psychopathological constructs that are eminently useful cannot be found or adequately describes in terms of the DSM - for example Munchausen's (which is distinct from factitious disorder), Ganser syndrome, acute polymorphic psychotic disorder, delirious mania, bvFTD phenocopy syndrome, late paraphrenia, demoralization syndrome, are important psychiatric syndromes but are nowhere to be found in the DSM-5.

 

[doc4us]

Thank you Splik. I think what you describe needs to be encouraged in our residency training. We value those attendings who encourage us "to think outside the box" do you think the popularity of the use of protocols or checklists are discouraging us to be creative in our clinical judgment?


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[OldPsychDoc]

Thank you Splik. I think what you describe needs to be encouraged in our residency training. We value those attendings who encourage us "to think outside the box" do you think the popularity of the use of protocols or checklists are discouraging us to be creative in our clinical judgment?

EMR templates don't exactly help, either.

 

[Shikima]

EMR templates don't exactly help, either.

Control-C then Control-P.

 

[Merovinge]

Plenty of psychopathological constructs that are eminently useful cannot be found or adequately describes in terms of the DSM - for example Munchausen's (which is distinct from factitious disorder), Ganser syndrome, acute polymorphic psychotic disorder, delirious mania, bvFTD phenocopy syndrome, late paraphrenia, demoralization syndrome, are important psychiatric syndromes but are nowhere to be found in the DSM-5.

Don't even need to get that rare. Polytrauma/complex trauma isn't remotely covered by the DSM5 and responsible for a such a large portion of our work, particularly for anyone in CAP.

 

[splik]

do you think the popularity of the use of protocols or checklists are discouraging us to be creative in our clinical judgment?

no i think the last thing we need is to return to the anarchy of the 1960s. Let's take a hypothetical patient who presents to 8 different psychiatrists. The first psychiatrist believes the patient has a schizophrenic reaction and prescribes chlorpromazine. The second psychiatrist believes the patient has melancholia and recommends imipramine hydrochloride. The third psychiatrist believes the patient has a manic-depressive psychosis and recommends electroshock treatment (as lithium is not available in the US). The fourth psychiatrist believes that the patient is playing mad in order to live in an unlivable situation and believes psychoanalysis is the only treatment possible of effecting anything close to a cure. The fifth psychiatrist believes the patient has a vitamin deficiency and recommends high dose niacin. The sixth psychiatrist believes the patient has a failure to separate from his parents and transition through adolescence and recommends family therapy. The seventh psychiatrist isn't quite sure what is going on, but insulin coma therapy usually helps in these cases. The eighth psychiatrist believes the patient is a hopeless schizophrenic and insists that prefrontal lobotomy is the most effective treatment.

"creativity" can hardly be justified if it leads to a patient garnering completely different diagnoses and treatments based entirely on the whims and fancies of the evaluating psychiatrist. It makes a mockery of the practice of medicine. checklists and protocols exist because of the failings of anarchy-based medicine. checklists ensure uniformity, improve quality, decrease costs, reduce errors, and act as a safeguard. they exist to drive up standards of care. and they do.

the problem isn't checklists or protocols but how they are applied. a good physician sees them as a tool or guideline for best practice but knows when to deviate or what to do when a patient doesn't fit into the checklist or protocol. an NP on the other hand uses the checklist or protocol as the sine qua non of practice and will not know what to do when the patient doesn't fit the protocol or checklist. so much of what we do is in an evidence-free zone there is plenty of ability to think outside the box and use one's clinical judgement. but where know that there are certain standards we should be rigorously adhering to them. unfortunately, sometimes checklists and protocols can be abused or overused to the point where they interfere with the doctor-patient relationships. The VA would be a good example. There are just too many forms to fill in, and enough sanctimonious pricks that will insist on you filling them all out even when they are completely irrelevant.

 

[nancysinatra]

no i think the last thing we need is to return to the anarchy of the 1960s. Let's take a hypothetical patient who presents to 8 different psychiatrists. The first psychiatrist believes the patient has a schizophrenic reaction and prescribes chlorpromazine. The second psychiatrist believes the patient has melancholia and recommends imipramine hydrochloride. The third psychiatrist believes the patient has a manic-depressive psychosis and recommends electroshock treatment (as lithium is not available in the US). The fourth psychiatrist believes that the patient is playing mad in order to live in an unlivable situation and believes psychoanalysis is the only treatment possible of effecting anything close to a cure. The fifth psychiatrist believes the patient has a vitamin deficiency and recommends high dose niacin. The sixth psychiatrist believes the patient has a failure to separate from his parents and transition through adolescence and recommends family therapy. The seventh psychiatrist isn't quite sure what is going on, but insulin coma therapy usually helps in these cases. The eighth psychiatrist believes the patient is a hopeless schizophrenic and insists that prefrontal lobotomy is the most effective treatment.

"creativity" can hardly be justified if it leads to a patient garnering completely different diagnoses and treatments based entirely on the whims and fancies of the evaluating psychiatrist. It makes a mockery of the practice of medicine. checklists and protocols exist because of the failings of anarchy-based medicine. checklists ensure uniformity, improve quality, decrease costs, reduce errors, and act as a safeguard. they exist to drive up standards of care. and they do.

the problem isn't checklists or protocols but how they are applied. a good physician sees them as a tool or guideline for best practice but knows when to deviate or what to do when a patient doesn't fit into the checklist or protocol. an NP on the other hand uses the checklist or protocol as the sine qua non of practice and will not know what to do when the patient doesn't fit the protocol or checklist. so much of what we do is in an evidence-free zone there is plenty of ability to think outside the box and use one's clinical judgement. but where know that there are certain standards we should be rigorously adhering to them. unfortunately, sometimes checklists and protocols can be abused or overused to the point where they interfere with the doctor-patient relationships. The VA would be a good example. There are just too many forms to fill in, and enough sanctimonious pricks that will insist on you filling them all out even when they are completely irrelevant.

This is an indictment of our field. Our field needs new leadership and more creative input, both at the national level and most importantly at the level of training programs. But, unfortunately, too many training directors go into their jobs because they fit the profile of bureaucrats. I realize that does not describe ALL PDs but it definitely describes some. So you can't count on training programs to lead psychiatry in a new direction. I'm sorry, but it's just not going to happen. Residencies exist to promote and protect the status quo. Same with the APA, and same with the ACGME.

Until imaging and lab tests can be used to make psychiatric diagnoses, and until the psychopharm industry is broken up, I think we are completely doomed. And I literally believe it will 500 years before those things happen. Plus, a lot of stuff that shows up in psychiatry is inherently psychological. Checklists and bureaucracies are not well-suited for the vagaries of psychology. Another reason why we're doomed.

I honestly don't believe I can help humanity by working in a field as messed up as psychiatry. All I can do as a psychiatrist is try to reduce polypharmacy, simplify diagnoses, and empathize with patients who complain about the economy or other social problems affecting their lives. But that's a futile role, and it's not why I went to medical school.

 

[Leo Aquarius]

I am a big fan of evidence based practice, but there are different kinds of evidence as well as different levels of evidence. some people have a very caricatured idea of what EBM is that would have David Sackett turning in his grave. At the same time the reality is that much of what we practice is in a evidence free zone. This is not just true of psychiatry but all of medicine. There are only large randomized controlled trials for certain things, and RCTs are neither necessary nor sufficient for establishing the evidence base for particular interventions. Even for those interventions that have been studied, the harms often are not (particularly in the case of psychotherapies, RCTs rarely report or study adverse events). Treatment in psychiatry starts with a good formulation and theoretical justification for the management plan. Being able to formulate a patient from multiple perspectives should be the essential skill of the psychiatrist and requires one to think "outside the box".

Another aspect of the "box" in diagnostic psychiatry is a very limited framework for conceptualizing mental distress - the DSM. Psychiatric diagnoses carve nature at the joints, are categorical rather than dimensional, assume mental disorders as "natural kinds" rather than "ideal types", and are shaped by cultural and sociopolitical factors more than medical or psychological ones. Thinking outside the box means being able to think outside the straightjacket of the DSM, a system of diagnosis that was meant to serve as guidebook and common language for the field and instead has been reified as a "bible". Plenty of psychopathological constructs that are eminently useful cannot be found or adequately describes in terms of the DSM - for example Munchausen's (which is distinct from factitious disorder), Ganser syndrome, acute polymorphic psychotic disorder, delirious mania, bvFTD phenocopy syndrome, late paraphrenia, demoralization syndrome, are important psychiatric syndromes but are nowhere to be found in the DSM-5.

The problem is human nature wants a box, but psychiatry is beyond boxes.

 

[birchswing]

The problem is human nature wants a box, but psychiatry is beyond boxes.

This makes it sound more like a religion, which would not preclude it from offering drugs, as you find cultural/religious practices of using coca leaves and marijuana.

 

[Leo Aquarius]

This makes it sound more like a religion, which would not preclude it from offering drugs, as you find cultural/religious practices of using coca leaves and marijuana.

No, it does not make it sound like a religion. The mind cannot be easily defined or made into checklists. Must the discussion of the mind invoke religion?

 

[Shikima]

No, it does not make it sound like a religion. The mind cannot be easily defined or made into checklists. Must the discussion of the mind invoke religion?

Yes. Because it offers more to the holistic care compared to those living secular lives who experience deep hopelessness. Research is there. By no means is he suggesting that people go to church to invoke a name.... Remember the biopsychosocial model.

 

[MidwestMD2015]

checklists and protocols exist because of the failings of anarchy-based medicine. checklists ensure uniformity, improve quality, decrease costs, reduce errors, and act as a safeguard. they exist to drive up standards of care. and they do.

the problem isn't checklists or protocols but how they are applied. a good physician sees them as a tool or guideline for best practice but knows when to deviate or what to do when a patient doesn't fit into the checklist or protocol.
...
so much of what we do is in an evidence-free zone there is plenty of ability to think outside the box and use one's clinical judgement. but where know that there are certain standards we should be rigorously adhering to them. unfortunately, sometimes checklists and protocols can be abused or overused to the point where they interfere with the doctor-patient relationships.

The problem is human nature wants a box, but psychiatry is beyond boxes.

Because it offers more to the holistic care compared to those living secular lives who experience deep hopelessness. Research is there.
...
Remember the biopsychosocial model.

The DSM-5 has an interesting focus in the early pages that is worth a read. Headings such as, "Dimensional Approach to Diagnosis", "Developmental and Lifespan Considerations", "Cultural Issues", "Gender Differences"--on and on.

I also especially like the section starting on Page 19 of DSM-5 on "Approach to clinical case formulation". Here's a section that is relevant:

Although decades of scientific effort have gone into developing the diagnostic criteria sets for the disorders included in Section II, it is well recognized that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals experience and present to clinicians on a daily basis throughout the world. As noted previously in the introduction, the range of genetic/environmental interactions over the course of human development affecting cognitive, emotional and behavioral function is virtually limitless. As a result, it is impossible to capture the full range of psychopathology in the categorical diagnostic categories that we are now using.

Lastly, there are lots of systems that try to protect from 'over-boxing' things--many of the systems are incomplete, but at least provide a structure (useful to me as an intern trying to figure this all out!) I was reading the Perspectives again, a useful synopsis here: "Beyond the DSM: The Perspectives of Psychiatry Approach to Patients"

 

[Leo Aquarius]

Yes. Because it offers more to the holistic care compared to those living secular lives who experience deep hopelessness. Research is there. By no means is he suggesting that people go to church to invoke a name.... Remember the biopsychosocial model.

Holistic is the path forward, but its shadow can be wholly free from a spiritual one. I never thought he meant church or anything organized. I disagree with the terms used. You and I actually agree but are faltering on semantics.

Biopsychosocial encompasses factors beyond biology. Every good doctor considers this on a daily basis.

(I guess my days studying philosophy at Cambridge is causing me to use a magnifying glass here. Anyway, carry on.)

 

[NickNaylor]

It seems to me that quality control in the production of doctors gets shunted to the next system (this would make a great paper; maybe someone has already written it?). Pardon me if this comes across as overly provocative (I have been riding a caffeine wave for three days preparing for a case):

QA certainly doesn't happen at the entry to medical school level. If you include allopathic, osteopathic, and international medical schools, pretty much anyone capable of graduating college successfully can get into medical school if they are willing to go anywhere and pay anything.

QA doesn't typically happen at the medical school graduation level. I'm not sure of the stats in general, but last I heard, U.S. allopaths graduate at a rate of about 95%. When you rule out folks who change careers, have health consequences, etc., I've heard that it's only about 1.5% of U.S. allopaths not graduating due to academic reasons. I know firsthand from doing education rep work in medical school that programs bend over backwards to make sure each person gets through the year. In ways that far exceed even what your average community college would do to get folks passed.

QA doesn't seem to happen at the residency level either. I'd be curious to hear from PDs on this, but I know that residents being kicked out for poor performance is extremely low, even in psychiatry (which although rising in competition is still not up there in requirements). I have met many, many residents that I would not want to refer patients to. And almost all folks I have heard about (in substantiated ways) that were kicked out from residency were for professionalism (sex, drugs, etc.) reasons rather than can't-execute-even-the-fundamentals. SDN seems rife with applicants wanting to tar any program that has ever given a resident the boot, even prior to hearing about circumstances.

QA doesn't seem to happen post-residency level much at all. From doing malpractice cases, I feel comfortable saying that a psychiatrists abilities have to be at the point of outright dangerous before they will lose their license or even get reprimanded.

I have no solutions. I just find it interesting that for such a safety-oriented field, we do not have a very good quality assurance process for how we create doctors.

One might argue that, from the perspective of the system, the illusion of safety and QA is more important than whether or not either occurs in fact.

 

[FlowRate]

One might argue that, from the perspective of the system, the illusion of safety and QA is more important than whether or not either occurs in fact.

Not sure why this thread was necrobumped, but I was thinking about that same post and the others regarding the difficulty of not-passing residents after reading through the thread. This is in many ways the same issue medicine is having, as a whole--how do you define quality?

Should you dismiss a resident for being a little odd or a little anxious? Probably not.

What about when they seem to have a very mild thought disorder (but they're otherwise not making wrong clinical decisions)? When their overwhelming anxiety causes significant efficiency issues (but not to the point that they're neglecting their duties)? How about when these things get so bad that other residents are picking up their slack or fixing their very suboptimal (but not obviously wrong) decisions?

What's the minimum level of psychopharm/psychopathological knowledge needed to be a competent psychiatrist? How do you assess for that? Pimping? Psychiatrists aren't great about pimping in the first place.

And I'm not sure how much this is true for other residency programs, but I've received very few formal evaluations over the course of residency. For that reason, I'm not sure that the program (at the PD level) is fully aware of exactly how bad coresident X is (because no one submits evals or maybe the attending doesn't see all the **** that the co-residents, psychologists, and social workers have to deal with in their aftermath.)

 

[WingedOx]

And I'm not sure how much this is true for other residency programs, but I've received very few formal evaluations over the course of residency. For that reason, I'm not sure that the program (at the PD level) is fully aware of exactly how bad coresident X is (because no one submits evals or maybe the attending doesn't see all the **** that the co-residents, psychologists, and social workers have to deal with in their aftermath.)

Your PD is always watching. He's like Santa.

 

[ziggyhope]

Your PD is always watching. He's like Santa.

For some reason, I read Santa as Satan...
Even though my PD is much more Santa like than Satan like, lol.

 

[clausewitz2]

Not sure why this thread was necrobumped, but I was thinking about that same post and the others regarding the difficulty of not-passing residents after reading through the thread. This is in many ways the same issue medicine is having, as a whole--how do you define quality?

Should you dismiss a resident for being a little odd or a little anxious? Probably not.

What about when they seem to have a very mild thought disorder (but they're otherwise not making wrong clinical decisions)? When their overwhelming anxiety causes significant efficiency issues (but not to the point that they're neglecting their duties)? How about when these things get so bad that other residents are picking up their slack or fixing their very suboptimal (but not obviously wrong) decisions?

What's the minimum level of psychopharm/psychopathological knowledge needed to be a competent psychiatrist? How do you assess for that? Pimping? Psychiatrists aren't great about pimping in the first place.

And I'm not sure how much this is true for other residency programs, but I've received very few formal evaluations over the course of residency. For that reason, I'm not sure that the program (at the PD level) is fully aware of exactly how bad coresident X is (because no one submits evals or maybe the attending doesn't see all the **** that the co-residents, psychologists, and social workers have to deal with in their aftermath.)

I similarly have not gotten that many formal evaluations (and in fact the one rotation where I got very extensive formal feedback, I panicked a bit and catastrophized until I found out this happened to everyone), but people talk. Attendings who have concerns about residents tend to talk more informally to the residency leadership, and certainly the promotion committees that I think are ACGME mandated to meet on a semi-regular basis are a forum for discussing everything all the members have observed or heard about each resident being considered. Also, I guarantee you some of those allied folks who are sufficiently disgruntled are bcc'ing email chains that are sufficiently egregious.

You probably know at this point how strong you are compared to your co-residents. Of course the people who probably should not be advanced often aren't the people who can make this judgement accurately, I suppose.

I think pimping is maybe less the answer versus actual case conferences with teeth, where one has to justify one's decisions and treatment rationales to reasonably vigorous questioning. That would be better for demonstrating useful, functional knowledge versus memorization of trivia, but it would have the drawback of rewarding rhetorically gifted BS'ers (although a bit of verbal flash to enhance placebo effects is probably a positive thing in this field!)

 

[NickNaylor]

Not sure why this thread was necrobumped

You're right - my bad. That's what I get from browsing on my phone. I got an alert from this thread and didn't check the dates.